Information Collection

Childcare Application Forms

IC 217805 under ICR 202112-3045-001 · OMB 3045-0142.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3045-0142 can be found here:

2025-03-04 - Extension without change of a currently approved collection

Documents and Forms

Document Name Document Type
Form 1 Childcare Application Forms Form and Instruction
1 Provider Application Child Care Provider Application 8-13-2021.docx www.nationalservice.gov Form and Instruction
1 Provider Application PROVIDER APPLICATION.docx www.nationalservice.gov Form and Instruction
2 Member Application AmeriCorps Childcare Member Application.docx www.nationalservice.gov Form and Instruction
2 Member Application MEMBER APPLICATION.docx www.nationalservice.gov Form and Instruction
3 Childcare Attendance Sheet AmeriCorps Child Care Attendance Sheet Invoice -updated 10-01-2021 per AmeriCorps request.pdf www.nationalservice.gov Form and Instruction
3 Childcare Attendance Sheet Attendance Sheet Invoice.pdf www.nationalservice.gov Form and Instruction
4 Statement of Work Activity STATEMENT OF WORK ACTIVITY.docx www.nationalservice.gov Form and Instruction
4 Statement of Work Activity STATEMENT OF WORK ACTIVITY.docx www.nationalservice.gov Form and Instruction
5 Member Update Form AmeriCorps Childcare Program - Member Update.docx www.nationalservice.gov Form and Instruction
5 Member Update Form MEMBER UPDATE FORM.docx www.nationalservice.gov Form and Instruction
6 Childcare Payment Authorization AmeriCorps Payment Authorization.docx www.americorps.gov Form and Instruction
6 Childcare Payment Authorization Payment Authorization.docx www.americorps.gov Form and Instruction
7 AmeriCorps Unlicensed Provider Affidavit AmeriCorps Unlicensed Provider Affidavit.docx www.americorps.gov Form and Instruction
7 AmeriCorps Unlicensed Provider Affidavit Unlicensed Provider Affidavit.docx www.americorps.gov Form and Instruction
8 Program Certification of Active Service AmeriCorps Program Certification of Active Service.docx www.americorps.gov Form and Instruction
8 Program Certification of Active Service Certification of Active Service.docx www.americorps.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Childcare Application Forms	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Provider Application	PROVIDER APPLICATION.docx	www.nationalservice.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	2	Member Application	MEMBER APPLICATION.docx	www.nationalservice.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	3	Childcare Attendance Sheet	Attendance Sheet Invoice.pdf	www.nationalservice.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	4	Statement of Work Activity	STATEMENT OF WORK ACTIVITY.docx	www.nationalservice.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	5	Member Update Form	MEMBER UPDATE FORM.docx	www.nationalservice.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	6	Childcare Payment Authorization	Payment Authorization.docx	www.americorps.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	7	AmeriCorps Unlicensed Provider Affidavit	Unlicensed Provider Affidavit.docx	www.americorps.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	8	Program Certification of Active Service	Certification of Active Service.docx	www.americorps.gov	Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title: Corporation for National and Community Service	FR Citation: 67 FR 20

Number of Respondents: 2,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,100	-150	2,250
Annual IC Time Burden (Hours)	1,050	-255	1,305
Annual IC Cost Burden (Dollars)	23,499	23,499	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.