Year-End Statement Request

(2011 Year-End Statements Available Beginning January 23, 2012)

Today's Date: 2/4/2012

If your child or children currently attend a Knowledge Beginnings Center or you have withdrawn from a Knowledge Beginnings Center, please see the Center Director to obtain your Year-End Statement.

Please complete this form ONLY if you are the parent or guardian of a child or children that attended a Knowledge Beginnings Center that is no longer open for business, or in the event the current Center Director is unable to furnish you with a copy of your Year-End Statement.

* Denotes a required field

Requester Information

*Tax Year Requested:

*First Name:

*Last Name:

*Mailing Address:

*City:

*State:

*ZIP:

*Phone:

Comments:

Center Information

*Mailing Address:

*City:

*State:

ZIP:

Your Children

Please include the first and last name for all children in your family that were enrolled for the tax year requested.

*First Name: *Last Name:

Distribution Information

*I certify that I am a parent or legal guardian of the above-listed child(ren), that the above information is accurate to the best of my knowledge, and that I am entitled to receive information regarding the total amount paid for tuition for the tax year: *

I wish to receive my year-end statement by email

Email:

I wish to receive my year-end statement by fax

Fax:

Please allow 7 business days to process your request.

As a service to our families, Knowledge Universe (parent company to KinderCare Learning Centers, Knowledge Beginnings and CCLC) offers this Year-End Statement to assist you in preparing your tax return. Our computerized records for 2011 show your total payments from 1/1/2011 to 12/31/2011 to be as stated above. These payments include fees and tuition, but may also cover services other than child care. Please make a copy of this statement for future reference regarding your child care payments for the year, as this record may have limited availability. Please keep additional records of your payments such as canceled checks, your bank or debit/credit statement, online payments and/or money order receipts in order to provide primary proof of payment in the event of an external audit or inquiry.

If you have any questions with respect to this statement, please contact your Center Director.

Year-End Statement Request

Requester Information

Center Information

Your Children

Distribution Information

We appreciate your being part of our family!