Disability Accommodation Request Form

OMB 3045-0179

This form is for use by AmeriCorps State and National grantees who want to receive reimbursement for funds spent accommodating AmeriCorps members with disabilities.

The latest form for Disability Accommodation Request Form expires 2023-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Disability Accommodation Reimbursement Request Form Form and Instruction
NCSA.pdf Supplementary Document
30-Day Disability Reimbursement_01-31-2023.pdf Supplementary Document
60-Day Disability Reimbursement_87 FR 68139_11-14-2022.pdf Supplementary Document
20230103 Days of Services Instructions SSA_UPDATED.docx Supporting Statement A
Disability Accommodation Reimbursement Request Form Form and Instruction

All Historical Document Collections

202301-3045-006 Approved with change	Extension without change of a currently approved collection	2023-01-31
202006-3045-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-06-25
201909-3045-002 Approved with change	Reinstatement without change of a previously approved collection	2019-09-10
201604-3045-002 Approved with change	New collection (Request for a new OMB Control Number)	2016-04-22