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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.