5 Member Update Form

AmeriCorps Childcare Program Member Update

Please use this form to notify GAP Solutions of changes to your AmeriCorps Child Care Benefit Application. If you are starting a new term with AmeriCorps you must submit a New AmeriCorps Member Child Care Application.

AmeriCorps Member Information

AmeriCorps Member Name: __________________________________

Member’s National Service Participant ID#: __________

(your NSPID # may be found in the My AmeriCorps Portal)

Change/Update to Child Care Application (check all that applies to you)

	Change of Address		Change of Work Site
	Change in Family Size		Change of Projected Service End Date
	Change in Marital Status		Change in Work Hours of Service
	Change in Household Income		Report Termination/Resignation from Service
	Adding or Removing Child to/from Benefit		New Child Care Provider (A NEW Provider Application must be submitted)
	Change in hours child needs child care		Other

Use the explanation of change section below to further describe the changes or updates to your current application on file. Submission of additional forms/supporting documentation relating to the changed indicated above may be required; a Child Care Coordinator will contact you should additional information be needed.

Explanation of Change

Use this space to explain and describe the change(s) indicated above:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

CONFIRMATION

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

_______________________________________________________ ______________

AmeriCorps Member’s 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

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