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Childcare Application Forms
Childcare Benefit Forms
OMB: 3045-0142
IC ID: 217805
OMB.report
CNCS
OMB 3045-0142
ICR 202409-3045-003
IC 217805
( )
Documents and Forms
Document Name
Document Type
Form 1
Childcare Application Forms
Form and Instruction
1 Provider Application
PROVIDER APPLICATION_2025.docx
www.nationalservice.gov
Form and Instruction
2 Member Application
MEMBER APPLICATION_2025.docx
www.nationalservice.gov
Form and Instruction
3 Childcare Attendance Sheet
Attendance Sheet Invoice.pdf
www.nationalservice.gov
Form and Instruction
4 Statement of Work Activity
STATEMENT OF WORK ACTIVITY.docx
www.nationalservice.gov
Form and Instruction
5 Member Update Form
MEMBER UPDATE FORM.docx
www.nationalservice.gov
Form and Instruction
6 Childcare Payment Authorization
Payment Authorization.docx
www.americorps.gov
Form and Instruction
7 AmeriCorps Unlicensed Provider Affidavit
Unlicensed Provider Affidavit.docx
www.americorps.gov
Form and Instruction
8 Program Certification of Active Service
Certification of Active Service.docx
www.americorps.gov
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Childcare Application Forms
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
1
Provider Application
PROVIDER APPLICATION_2025.docx
www.nationalservice.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
2
Member Application
MEMBER APPLICATION_2025.docx
www.nationalservice.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
3
Childcare Attendance Sheet
Attendance Sheet Invoice.pdf
www.nationalservice.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
4
Statement of Work Activity
STATEMENT OF WORK ACTIVITY.docx
www.nationalservice.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
5
Member Update Form
MEMBER UPDATE FORM.docx
www.nationalservice.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
6
Childcare Payment Authorization
Payment Authorization.docx
www.americorps.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
7
AmeriCorps Unlicensed Provider Affidavit
Unlicensed Provider Affidavit.docx
www.americorps.gov
Yes
Yes
Fillable Fileable Signable
Form and Instruction
8
Program Certification of Active Service
Certification of Active Service.docx
www.americorps.gov
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Community and Social Services
Subfunction:
Community and Regional Development
Privacy Act System of Records
Title:
CNCS-06-CPO-ACB-AmeriCorps Child Care Benefit System
FR Citation:
84 FR 46002
Number of Respondents:
1,040
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,040
0
0
-1,060
0
2,100
Annual IC Time Burden (Hours)
520
0
0
-530
0
1,050
Annual IC Cost Burden (Dollars)
11,638
0
0
-11,861
0
23,499
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.