4 Statement of Work Activity

AmeriCorps Child Care Statement of Work Activity

AmeriCorps Members: Please use this form if there is a member in your household over 18 years old who is either an independent contractor or is self-employed. Please complete this form in its entirety; incomplete forms will result in a delay in the processing your Child Care Benefit Application.

Name		Occupation Title			Relationship to AmeriCorps Member
Type of Employment Check which applies to you
	Full Time			I am an independent contractor
	Part Time			I operate my own business/I am self-employed
	Seasonal (describe your seasonal schedule below:			Other (provide explanation below)

Use this space to explain any of the items above: ______________________________________________________________________________________________________________________________________________________________________________________________________

Complete the table below to document your work schedule:

Number of Hours Worked per Week	Start Date of Employment (MM/DD/YY)	Work Schedule to include the hours of day and days of the week	Monthly Wages	How Often are you Paid?
Example: 40hours	04/16/2012	MWF 8-5pm TH 9-6pm	$2100	biweekly

Once you have completed this form, please fax it along with the following supporting documents to GAP Solutions at 1-800-521-5415.

Independent contractors must submit:

• Copy of most recent 1040 Federal Tax Return (including all schedules).

• 1 month of check pay-stubs for work performed by hiring company.

Self-employed Business Owners must submit:

• Copy of most recent 1040 Federal Tax Return (including all schedules)

• Unexpired copy of Business License.

• Business Profit/Loss Statements for the last 3 Months.

I confirm that the information provided in this Statement of Work Activity form (and any supporting documentation I provide) is true, correct and complete to the best of my ability, knowledge, and belief.

___________________________________ ____________________

Household member signature Date

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