3 Childcare Attendance Sheet

Member Name: _______________________________________ Member E-Mail Address: _______________________________

Provider Name: Provider Telephone #: _________________________________

Month of Care: _________________________________ Year of Care: ______________________________ State: ______

TABLE A: CHILDREN IN CARE
Child Name	Age	Rate for this child (ex: $100/weekly)
1.
2.
3.
4.

*Please type the letter “A” for days that your child is absent or sick, type “H” for Holidays and “W” for weekends*

TABLE B: Fill in the # of hours each day care was provided
Days of the Month	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15
Child 1:
Child 2:
Child 3:
Child 4:
Days of the Month	16	17	18	19	20	21	22	23	24	25	26	27	28	29	30	31
Child 1:
Child 2:
Child 3:
Child 4:

TABLE C: INVOICE CHARGES
WEEK 1	$
WEEK 2	$
WEEK 3	$
WEEK 4	$
WEEK 5	$
TOTAL INVOICE CHARGES	$

X

Provider Signature Date

I certify that the provider information and attendance record entered on this attendance sheet are true and accurate. I understand that my payment will be in accordance with the CCDF Block Grant program guidelines for my state. I further understand that any misrepresentation of information may result in legal action.

X

Member Signature Date

I certify that the information provided above and the attendance records entered on this attendance sheet are true and accurate. I understand that my payment will be in accordance with the CCDF Block Grant program guidelines for my state. I further understand that any misrepresentation of information may result in legal action.

The information requested on the AmeriCorps Childcare Application forms is collected pursuant to 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C. 4953 of the Domestic Volunteer Service Act of 1973 as amended. Purposes and Uses - The information requested is collected to evaluate applications for the childcare subsidy made available to AmeriCorps members by law, and to evaluate applications to provide the childcare. Routine Uses - Routine uses may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information may also be provided to appropriate federal agencies and contractors that have a need to know the information for the purpose of assisting the agency’s efforts to respond to a suspected or confirmed breach of the security or confidentiality or information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance. The information will not otherwise be disclosed to entities outside of AmeriCorps and CNCS without prior written permission. Effects of Nondisclosure - The information requested is mandatory in order to receive benefits. 

OMB Control Number: 3045-0142

Expiration: October 31, 2018

*Upon receipt of a completed Attendance Sheet, payment will go out in the form of a check within 15-30 Business Days. (Incomplete attendance sheets will NOT be processed)

Form Updated 04/2013