AmeriCorps Member Application, Enrollment, and Exit Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 2015 AmeriCorps Member Application	Form and Instruction	Removed	Available
Form 3 AmeriCorps Member Application 12.7.12	Form and Instruction	Removed	Available
Form 2011-1 2011 Member Application	Form and Instruction	Removed	Available
Form SEC -618 Americorps Member Application	Form and Instruction	Removed	Available
Form SEC -618 AmeriCorps Member Application	Form and Instruction	Removed	Repair queued
Form 2 AmeriCorps Enrollment and Exit Form	Form	New	Available
Form 1 AmeriCorps Member Application	Form and Instruction	New	Available
Form 1 AmeriCorps Member Application, Enrollment, and Exit Form	Form and Instruction	New	Repair queued
National and Community Service Act of 1990.pdf	Supplementary Document	Uploaded 2022-02-09	Repair queued
Justification for Non-Substantive Change 12.7.12.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2012-12-07	Repair queued
List of Revisions AC Member App 12.6.12.docx	Supplementary Document	Uploaded 2012-12-07	Repair queued
20220126 AmeriCorps Member Application Enrollment and Exit FormSSA v1.docx	Supporting Statement A	Uploaded 2022-02-09	Repair queued
Justification for Change in AmeriCorps Member Application 1.13.11.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2011-01-24	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
29268	AmeriCorps Member Application	Form and Instruction	Removed	2015 AmeriCorps Member Application
29268	AmeriCorps Member Application	Form and Instruction	Removed	AmeriCorps Member Application 12.7.12
29268	AmeriCorps Member Application	Form and Instruction	Removed	2011 Member Application
29268	AmeriCorps Member Application	Form and Instruction	Removed	Americorps Member Application
29268	AmeriCorps Member Application	Form and Instruction	Removed
251499	AmeriCorps Member Application, Enrollment, and Exit Form	Form	New	AmeriCorps Enrollment and Exit Form
251499	AmeriCorps Member Application, Enrollment, and Exit Form	Form and Instruction	New	AmeriCorps Member Application
251499	AmeriCorps Member Application, Enrollment, and Exit Form	Form and Instruction	New

ICR Details

OMB Control No: 3045-0054	ICR Reference No: 202202-3045-001
Status: Historical Active	Previous ICR Reference No: 201812-3045-001
Agency/Subagency: CNCS	Agency Tracking No:
Title: AmeriCorps Member Application, Enrollment, and Exit Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/07/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/09/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2025	36 Months From Approved	04/30/2022
Responses	521,000	0	225,000
Time Burden (Hours)	390,750	0	281,250
Cost Burden (Dollars)	12,946,850	0	0

---

Abstract: AmeriCorps is soliciting comments concerning its proposed new AmeriCorps Member Application, Enrollment, and Exit Form. Applicants will respond to the questions included in this information collection tool to apply to serve as AmeriCorps members, enroll in the National Service Trust, and exit their term of service.

---

Authorizing Statute(s): US Code: 42 USC 12501 et seq Name of Law: National and Community Service
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 68487	12/02/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 6852	02/07/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
AmeriCorps Member Application	2011-1, SEC -618, 3, 4	Americorps Member Application ,   2011 Member Application ,   AmeriCorps Member Application 12.7.12 ,   2015 AmeriCorps Member Application
AmeriCorps Member Application, Enrollment, and Exit Form	2, 1	AmeriCorps Member Application ,   AmeriCorps Enrollment and Exit Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	521,000	225,000	0	296,000	0	0
Annual Time Burden (Hours)	390,750	281,250	0	109,500	0	0
Annual Cost Burden (Dollars)	12,946,850	0	0	12,946,850	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden has increased because we have added the AmeriCorps Enrollment and Exit Forms (former 3045-0006) to this ICR in anticipation of IT modernization which will result in a single form. The burden shows a decrease because we removed the former ICR.

---

Annual Cost to Federal Government: $4,315,182

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/09/2022

---