5 Member Update Form

Childcare Application

MEMBER UPDATE FORM

OMB: 3045-0142

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AmeriCorps Childcare Program - Member Update Picture 1


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


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.



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 Childcare 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 Childcare Provider (A new Provider Application must be submitted)


Change in hours child needs childcare


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 Childcare Coordinator will contact you should additional information be needed.


Explanation of Change


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

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________



AmeriCorps Member 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




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


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMonica L. Streeter
File Modified0000-00-00
File Created2022-03-07

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