7 AmeriCorps Unlicensed Provider Affidavit

^{AmeriCorps Childcare Unlicensed Provider Affidavit}

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.

I, __________________________, have selected ___________________________ to be my

(Member’s Name) (Provider’s Name)

childcare provider.  I understand that my state of residence highly encourages parents to run a criminal background check on all unlicensed childcare providers as does CNCS.  To that end, the link for checking whether the childcare provider I have selected is a registered sex offender is: https://www.nsopw.gov/

The link for checking whether my selected unlicensed childcare provider is on a state registry is here (not available in all states): https://www.nationalservice.gov/documents/2017/cncs-designated-state-criminal-history-information-repositories-and-alternatives

I assume full responsibility for conducting a criminal background check on the childcare provider I have selected. I understand that I must notify GAP Solutions of any childcare provider changes. 

Member relationship to childcare provider:  __________________________

___________________________________                                           _______________

AmeriCorps Member’s Signature                                                   Date

OMB No.: 3045-0142 expires 12-31-2021