3 Childcare Attendance Sheet

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 child care 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 child care benefit, (2) individuals and
organizations providing child care, and (3) federal, state, or local agencies pursuant to lawfully authorized requests. Effects of Nondisclosure
– This request is voluntary, but not providing the information will likely affect your ability to receive child care benefits.
Member Name: _______________________________________________

Member E-Mail Address: ____________________________________

Provider Name: ____________________________

Provider E-Mail Address: ___________________________________

___

Month of Care: _________________________________
CHILDREN IN CARE:
Child Name

Year of Care: ______________________________ State: __________
Age

Childcare Provider Rate (Ex: $100/weekly)

1.
2.
3.

Instructions: Fill in the total # of hours each day care was provided (Ex: If care was provided from 8am-5pm you
would write “9” in the box below). Please use the letter “A” for absent/sick,“H” for holidays, and “W” for weekends.
Days of the Month

Child 1:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Child 2:
Child 3:
Days of the Month

Child 1:

31

Child 2:
Child 3:

INVOICE CHARGES: Please add up your weekly charges for the month
WEEK 1

$

WEEK 2

$

WEEK 3

$

WEEK 4

$

WEEK 5

$

TOTAL INVOICE CHARGES

$

X

Provider Signature

Date

X

Member 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.
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.

*Upon receipt of a completed Attendance Sheet, payment will be made within 10 business days (Incomplete attendance
sheets will NOT be processed)
OMB Control Number: 3045-0142 expires 12-31-2021