Childcare Benefit Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 8 Program Certification of Active Service	Form and Instruction	Modified	Repair queued
Form 7 AmeriCorps Unlicensed Provider Affidavit	Form and Instruction	Modified	Repair queued
Form 6 Childcare Payment Authorization	Form and Instruction	Modified	Repair queued
Form 5 Member Update Form	Form and Instruction	Modified	Repair queued
Form 4 Statement of Work Activity	Form and Instruction	Modified	Repair queued
Form 3 Childcare Attendance Sheet	Form and Instruction	Modified	Repair queued
Form 2 Member Application	Form and Instruction	Modified	Repair queued
Form 1 Provider Application	Form and Instruction	Modified	Repair queued
Form 1 Childcare Application Forms	Form and Instruction	Modified	Available
30-day Notice_Childcare_03-04-2025.pdf	Supplementary Document	Uploaded 2025-03-04	Repair queued
30-day Notice_Childcare_03-04-2025.pdf	Supplementary Document	Uploaded 2025-03-04	Repair queued
60-Day_12-17-2024.pdf	Supplementary Document	Uploaded 2025-03-04	Repair queued
60-Day_12-17-2024.pdf	Supplementary Document	Uploaded 2025-03-04	Repair queued
42 USC 12594.pdf	Supplementary Document	Uploaded 2025-03-04	Repair queued
42 USC 12594.pdf	Supplementary Document	Uploaded 2025-03-04	Repair queued
Childcare Application SSA_2025.docx	Supporting Statement A	Uploaded 2025-03-04	Repair queued
Childcare Application SSA_2025.docx	Supporting Statement A	Uploaded 2025-03-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217805	Childcare Application Forms	Form and Instruction	Modified	Program Certification of Active Service
217805	Childcare Application Forms	Form and Instruction	Modified	AmeriCorps Unlicensed Provider Affidavit
217805	Childcare Application Forms	Form and Instruction	Modified	Childcare Payment Authorization
217805	Childcare Application Forms	Form and Instruction	Modified	Member Update Form
217805	Childcare Application Forms	Form and Instruction	Modified	Statement of Work Activity
217805	Childcare Application Forms	Form and Instruction	Modified	Childcare Attendance Sheet
217805	Childcare Application Forms	Form and Instruction	Modified	Member Application
217805	Childcare Application Forms	Form and Instruction	Modified	Provider Application
217805	Childcare Application Forms	Form and Instruction	Modified

ICR Details

OMB Control No: 3045-0142	ICR Reference No: 202409-3045-003
Status: Active	Previous ICR Reference No: 202112-3045-001
Agency/Subagency: CNCS	Agency Tracking No:
Title: Childcare Benefit Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/15/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/04/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2028	36 Months From Approved	04/30/2025
Responses	1,040	0	2,100
Time Burden (Hours)	520	0	1,050
Cost Burden (Dollars)	11,638	0	23,499

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Abstract: These forms are submitted by AmeriCorps members and by childcare providers for the purpose of applying for, and receiving payment for the care of children during the day while the AmeriCorps members are serving.

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Authorizing Statute(s): US Code: 42 USC 12501 et seq Name of Law: National Community Service Act of 1990 as amended
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 102118	12/17/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 11158	03/04/2025
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Childcare Application Forms	6, 2, 3, 1, 4, 5, 7, 8	Provider Application ,   Member Application ,   Childcare Attendance Sheet ,   Statement of Work Activity ,   Member Update Form ,   Childcare Payment Authorization ,   AmeriCorps Unlicensed Provider Affidavit ,   Program Certification of Active Service

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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	1,040	2,100	0	0	-1,060	0
Annual Time Burden (Hours)	520	1,050	0	0	-530	0
Annual Cost Burden (Dollars)	11,638	23,499	0	0	-11,861	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been a change in burden hours due to an adjustment in agency estimate because AmeriCorps decreased its estimate of respondents from 2,100 to 1,040 based on a decrease in childcare benefit requests over the past few years.

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Annual Cost to Federal Government: $187,000

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

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Common Form ICR:  No

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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: 03/04/2025

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