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AmeriCorps
Childcare - Member Application
Instructions:
This application form must be completed in its entirety prior to
submission to GAP Solutions, Inc.; failure to complete any
section may delay the processing of your application. Please
write N/A (non-applicable) in the space provided should the
question not apply to you.
A
Member Checklist is available for you at
http://www.americorpschildcare.com.
It outlines all of the required supporting documentation needed
to accompany your application when it is submitted.
Privacy
Act Statement (PAS)
Authorities
– This
information is requested pursuant to the National and Community
Service Act of 1990 as amended (42 USC 12501 et
seq.),
the Domestic Volunteer Service Act of 1973 as amended (42 USC
4950 et
seq.),
and E.O. 9397 as amended. Purposes
–
It is requested to manage, administer, and evaluate the
childcare benefits program offered to eligible AmeriCorps
Service
Members. Routine
Uses –
Routine uses of this information may include disclosure to (1)
contractors to assist with administering the childcare benefit,
(2) individuals and organizations providing childcare, and (3)
federal, state, or local agencies pursuant to lawfully
authorized requests. A complete list of uses can be found in the
system of records notice associated with this collection of
information, CNCS–06–CPO–ACB–AmeriCorps
Child Care Benefit System (ACB).
Effects
of Nondisclosure
– This request is voluntary, but not providing the
information will likely affect your ability to receive childcare
benefits.
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MEMBER
INFORMATION
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AmeriCorps
Member Name: (Last,
First, Middle Initial)
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Member’s
National Service Participant ID #
__________________
Your NSPID # can be found
in the MyAmeriCorps Portal
(if
available)
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Type
of Application:
For
first time applicants.
For
members beginning a new term.
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AmeriCorps
Program: (State/National, VISTA, NCCC/FEMA)
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Start
date of Service
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End
date of Service
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Date
of Birth:
____/____/______
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AmeriCorps
Member Email Address:
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Home
Phone Number
(____)-____-_______
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Cell
Phone Number
(____)-____-_______
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Street
Address:
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City:
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State:
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Zip
Code:
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Full
time residence?
Yes
No
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SPOUSE/DOMESTIC
PARTNER INFORMATION
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Name:
(Last,
First, Middle Initial)
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Street
Address:
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City:
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State:
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Zip
Code:
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Phone
Number:
(____)-____-_______
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Email
Address:
_________________________
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Employment
Status:
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If
your spouse/domestic partner is unemployed, please complete the
information below:
Last
date of employment: __/__/____
Name
of Last Employer:
_______________________________________
Former
Position: _______________________________________
Supervisor
Name:
________________________________________
Telephone
Number: (____)-____-_______
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Is
your spouse/domestic partner completing Job Training/Educational
Program?
If
you answered yes, please complete section below:
Name
of Training/Educational Institution:
_______________________________________
Start
Date: __/__/____
Projected
End Date: __/__/____
Enrollment
Status:
Full
Time
Part Time
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HOUSEHOLD
INFORMATION
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List
all
members of your household below
For
all children listed, please include relationship as
biological,
adopted, step child, foster, etc.
Total
# of household members _______
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NAME
OF HOUSEHOLD MEMBER
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AGE
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GENDER
(M/F)
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RELATIONSHIP
TO MEMBER
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SELF
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INFORMATION
FOR CHILD(REN) NEEDING CHILDCARE
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Child’s
Name
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Is
this child currently receiving any federal/state childcare
subsidy?
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Is
this child enrolled in school?
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YES
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NO
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YES
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NO
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SCHOOL
INFORMATION
For
all school aged children, please fill in the table below to
determine the type of care needed.
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CHILD’S
NAME
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NAME
OF SCHOOL
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GRADE
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SCHOOL
SCHEDULE
Example:
9 am – 2 pm.
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CHILD
CUSTODY
Please
note: If you are a single parent household, you are required
to provide proof of custody. Attach
the child custody arrangement portion of your court order. An
affidavit or written statement must be submitted if
informally agreed upon. Other documents may be requested if
legal custody order doesn’t exist.
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CHILD’S
NAME
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SCHEDULE
OF CHILDCARE NEED
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Fill
in the boxes below with the hours your child will need care
Example:
8 am – 6 pm
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SUN
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MON
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TUE
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WED
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THU
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FRI
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SAT
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SUMMARY
OF HOUSEHOLD INCOME
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List
the total Monthly
Family
Income. That includes but is not limited to AmeriCorps Member,
Spouse, Domestic Partner or Child’s Other parent if they
live in your home. All boxes must be completed; please
write N/A (non-applicable) if the question does not apply to
you.
If
you or your household members are self-employed, please have
them complete the Statement
of Work Activity Form.
FORM
OF INCOME
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AmeriCorps
Member
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Spouse/Domestic
Partner/Other Legal Parent
_____________
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Wages,
Salaries & Tips
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AmeriCorps
Stipend
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Self-Employment
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Adoption
subsidies / Foster care payments
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Alimony
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Child
Support
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Nutritional
Programs (ex: SNAP)
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Housing
allotments or assistance
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Military
housing or other allotment / bonuses
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Scholarships,
education loans, grants, or income from work study
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Social
Security Income
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Veteran
Benefits
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Unemployment
Benefits
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Temporary
Assistance for Needy Families (TANF)
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Worker’s
Compensation
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Other:
_________________
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TOTAL:
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$_________________
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$_________________
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Disclaimer
– Documentation
will be required to support each of the declared forms of
income.
Please be sure to attach these documents with your
application when you submit the application.
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AMERICORPS
MEMBER CONFIRMATION
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Please
initial
each box to verify that you have read and understand the
policies listed below:
I
certify that:
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I
am the parent or legal guardian of the child(ren) listed in
this application and understand that I may have to present
documentation to confirm physical custody of the child
needing care to be eligible for the AmeriCorps Childcare
Benefit Program.
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I
need the AmeriCorps Childcare Program benefit in order to
serve.
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All
information submitted in this application is true and correct
and I understand that any misrepresentation or falsification
of information may result in prosecution under applicable
state and federal law.
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My
total family household income has been reported.
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I
understand
that:
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The
information on this application and supporting documentation
is required to determine my eligibility for the benefit.
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The
AmeriCorps Childcare staff may verify any information on this
application at any time they deem necessary.
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The
childcare benefit for which I may be eligible is based on
income, household size, age of child(ren), the
provider/program license type, and the provider/programs
location. If
there are any changes to my situation, I must report all
changes to the AmeriCorps Childcare Program immediately.
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I
must notify the AmeriCorps Childcare Program if and when my
service status changes or ends. I understand that my
eligibility ends on my last day of service.
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I
must select a qualified childcare provider/program that meets
state and federal qualifications necessary to participate in
the AmeriCorps Childcare Program. The
AmeriCorps Childcare Program is under no obligation to begin
payments until the provider/program has met all prerequisites
as described in my state’s Childcare Development Fund
Plan.
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I
must give the AmeriCorps Childcare Program a minimum of 2
weeks’ notice when changing childcare
providers/programs and must turn in all necessary paperwork
to process such provider. (See Provider Checklist under FORMS
on www.americorpschildcare.com
).
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I
may use more than one provider (or use a back-up provider);
The AmeriCorps Childcare Program will not
pay for the same period of care for the same child, to
multiple providers.
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The
AmeriCorps Childcare Program will only make all payments to
my childcare provider.
Payments are distributed on a monthly basis, after the month
of care has been provided. Payments are processed within 10
business days of receipt of a completed attendance sheet.
You,
the
AmeriCorps Member, are responsible for paying all childcare
charges in excess of the childcare benefit amount.
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AmeriCorps
members may not claim a childcare benefit from AmeriCorps
while also receiving a childcare benefit from another source.
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I
understand that accepting childcare support for the same
service for the same child may result in prosecution under
applicable state and federal law.
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I
understand that AmeriCorps is not legally required to make
payments to the childcare provider if I refuse childcare
services.
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I
understand/certify that I have read all of the above and
understand its content. I also understand that non-compliance
with any of the above may result in termination of my
participation in the AmeriCorps Childcare Program and that I may
be required to re-pay any money paid on my behalf and any
misrepresentation of information may result in prosecution under
applicable state and federal law.
_________________________________
__________________________ ____________
AmeriCorps Member Name (please print) AmeriCorps
Member Signature Today’s Date
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OMB No.: 3045-0142 expires 12-31-2021 Page 2
of 2
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Monica L. Streeter |
File Modified | 0000-00-00 |
File Created | 2022-03-07 |