4 Statement of Work Activity

^{AmeriCorps Childcare Statement of Work Activity}

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.

AmeriCorps Members: Please complete this form if you or your spouse or the other parent in your household if either work as an independent contractor or is self-employed.

Name		Occupation Title			Relationship to AmeriCorps Member
Type of Employment (please 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: 40	04/16/12	MWF 8-5pm / Tues 9-6pm	$2100	Biweekly

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.

Uploading the documents via our online application and faxing are the most secure methods of sending documents to our office.  If you do decide to email any of your documents, please ensure you encrypt the documents, then send the documents in one email and the password in a separate email.  That will help protect your information from any unintended recipients. 

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.

__________________________________ ___________________ Signature of Household Member Date

OMB Control Number.: 3045-0142 expires 12-31-2021