DR 1318 (08/05/21)
                                                   COLORADO DEPARTMENT OF REVENUE
                                                   Tax.Colorado.gov
*211318==19999*                                    Page 1 of 2

       Unlicensed Child Care Organization Registration Application

Organization Name

FEIN                                                                              Colorado Account Number, if applicable

Indicate Type of Organization

     Individual                                    Limited Liability Limited  Estate          Non-Profit 501(C)(3)
                                                   Partnership (LLLP)                         (Please enclose 
     General Partnership                           Corporation                Government      a copy of the 
                                                                                              IRS letter of 
     Limited Partnership                           S Corporation              Joint Venture   exemption)

     Limited Liability Company (LLC)               Association                Trust           Other Non-Profit

     Limited Liability Partnership                 Other, please explain below
     (LLP)

Trade Name/Doing Business As, if applicable

Address of Principal Place of Business in Colorado                                City        State            ZIP

County                                                                            Phone Number

In Care of (C/O) - Last Name                       First Name                                                  Middle Name

Mailing Address (if different from above)                                         City        State            ZIP

Check One

     Register an unlicensed child care program that                   Register a training program for child care providers
     serves at least 5 children age 12 and younger who 
     are not related to the owner, operator, or manager

     Register a grant or loan program for parents in                  Register an information dissemination program in 
     Colorado requiring financial assistance for child care           Colorado to provide information and referral services 
                                                                      to assist parents in obtaining child care

Check All That Apply
Programs serves:                                                 Does your facility and/or programs operate:
     Children 12 years of age and younger                             Before school

     Children 13 to 18 years of age                                   During school

     Adults 18 years of age and older                                 After school

                                                DR 1318 (08/05/21)
                                                COLORADO DEPARTMENT OF REVENUE
                                                Tax.Colorado.gov
*211318==29999*                                 Page 2 of 2
Organization Name

FEIN                                                                           Colorado Account Number, if applicable

Provide a description of your organization, including its stated purpose or mission

Provide a description of each of the programs offered by your organization

Explain why donations to this organization qualify for the child care contribution credit (see instructions)

Do all of your programs qualify for the credit? If yes, skip the next three questions and continue 
                                                                                                       Yes           No
with the next question thereafter. If no, answer the next three questions.
If no, specify which programs do qualify

Will your organization maintain a segregated account for funds dedicated exclusively to qualifying 
                                                                                                       Yes           No
programs Rule 39-22-121(10)(c)?
If no, and your organization must therefore issue credit certificates reflecting prorated credits, list the percentage of your 
programs that qualify and state how that percentage was determined (Rule 39-22-121(10)(b)). Attach with this application 
an explanation of how the percentage was determined.
                                                           Percentage of programs that qualify:                        %
Why is a Department of Human Services license not required (12 CCR 2509-8, 7.701.11)?

Attach copies of brochures, newspaper articles, community publications and other documentation to support 
the information above.

     I attest that the qualified program(s) provide I attest that my organization is not a licensed child care facility 
     for the care of five or more children who      and does not engage in programs that provide services 
     are not related to the owner, operator, or     identical or similar to day treatment centers, guest child care 
     manager.                                       facilities, family child care homes, foster care homes, homeless 
                                                    youth shelters, medical foster care, residential care facilities, 
                                                    secure residential treatment centers, specialized group 
                                                    facilities, or therapeutic foster care.
I declare under the penalty of perjury in the second degree that the statements made in this application are true 
and complete to the best of my knowledge
Name of Organization Officer                                              Title

Signature of Organization Officer                                                                  Date