2 Member Application

^{AmeriCorps Childcare - Member Application}

Instructions: This application form must be completed in its entirety prior to submission to GAP Solutions, Inc.; failure to complete any section may delay the processing of your application. Please write N/A (non-applicable) in the space provided should the question not apply to you.

A Member Checklist is available for you at http://www.americorpschildcare.com. It outlines all of the required supporting documentation needed to accompany your application when it is submitted.

Privacy Act Statement (PAS)

Authorities – This information is requested pursuant to the National and Community Service Act of 1990 as amended (42 USC 12501 et seq.), the Domestic Volunteer Service Act of 1973 as amended (42 USC 4950 et seq.), and E.O. 9397 as amended. Purposes – It is requested to manage, administer, and evaluate the childcare benefits program offered to eligible AmeriCorps Service Members. Routine Uses – Routine uses of this information may include disclosure to (1) contractors to assist with administering the childcare benefit, (2) individuals and organizations providing childcare, and (3) federal, state, or local agencies pursuant to lawfully authorized requests. A complete list of uses can be found in the system of records notice associated with this collection of information, CNCS–06–CPO–ACB–AmeriCorps Child Care Benefit System (ACB). Effects of Nondisclosure – This request is voluntary, but not providing the information will likely affect your ability to receive childcare benefits.

MEMBER INFORMATION

AmeriCorps Member Name: (Last, First, Middle Initial)

Member’s National Service Participant ID #

__________________

Your NSPID # can be found in the MyAmeriCorps Portal

(if available)

Type of Application:

• New Application

For first time applicants.

• Re-Enrollment Application

For members beginning a new term.

AmeriCorps Program: (State/National, VISTA, NCCC/FEMA)

Start date of Service

End date of Service

Date of Birth:

____/____/______

AmeriCorps Member Email Address:

Home Phone Number

(____)-____-_______

Cell Phone Number

(____)-____-_______

Street Address:

City:

State:

Zip Code:

Full time residence?

Yes No

SPOUSE/DOMESTIC PARTNER INFORMATION

Name: (Last, First, Middle Initial)

Street Address:

City:

State:

Zip Code:

Phone Number:

(____)-____-_______

Email Address:

_________________________

Employment Status:

• Employed

• Unemployed (fill in the next section)

If your spouse/domestic partner is unemployed, please complete the information below:

Last date of employment: __/__/____

Name of Last Employer:

_______________________________________

Former Position: _______________________________________

Supervisor Name:

________________________________________

Telephone Number: (____)-____-_______

Is your spouse/domestic partner completing Job Training/Educational Program?

If you answered yes, please complete section below:

Name of Training/Educational Institution:

_______________________________________

Start Date: __/__/____

Projected End Date: __/__/____

Enrollment Status:

Full Time  Part Time

HOUSEHOLD INFORMATION

List all members of your household below For all children listed, please include relationship as biological, adopted, step child, foster, etc. Total # of household members _______
NAME OF HOUSEHOLD MEMBER	AGE	GENDER (M/F)	RELATIONSHIP TO MEMBER
			SELF

INFORMATION FOR CHILD(REN) NEEDING CHILDCARE

Child’s Name	Is this child currently receiving any federal/state childcare subsidy?					Is this child enrolled in school?
	YES		NO			YES				NO
										
										
										
										
										
SCHOOL INFORMATION For all school aged children, please fill in the table below to determine the type of care needed.
CHILD’S NAME	NAME OF SCHOOL				GRADE			SCHOOL SCHEDULE Example: 9 am – 2 pm.
CHILD CUSTODY Please note: If you are a single parent household, you are required to provide proof of custody. Attach the child custody arrangement portion of your court order. An affidavit or written statement must be submitted if informally agreed upon. Other documents may be requested if legal custody order doesn’t exist.
CHILD’S NAME	SCHEDULE OF CHILDCARE NEED
	Fill in the boxes below with the hours your child will need care Example: 8 am – 6 pm
	SUN	MON	TUE	WED			THU		FRI		SAT

SUMMARY OF HOUSEHOLD INCOME

List the total Monthly Family Income. That includes but is not limited to AmeriCorps Member, Spouse, Domestic Partner or Child’s Other parent if they live in your home. All boxes must be completed; please write N/A (non-applicable) if the question does not apply to you. If you or your household members are self-employed, please have them complete the Statement of Work Activity Form.

FORM OF INCOME	AmeriCorps Member	Spouse/Domestic Partner/Other Legal Parent _____________
Wages, Salaries & Tips
AmeriCorps Stipend
Self-Employment
Adoption subsidies / Foster care payments
Alimony
Child Support
Nutritional Programs (ex: SNAP)
Housing allotments or assistance
Military housing or other allotment / bonuses
Scholarships, education loans, grants, or income from work study
Social Security Income
Veteran Benefits
Unemployment Benefits
Temporary Assistance for Needy Families (TANF)
Worker’s Compensation
Other: _________________
TOTAL:	$_________________	$_________________
Disclaimer – Documentation will be required to support each of the declared forms of income. Please be sure to attach these documents with your application when you submit the application.

AMERICORPS MEMBER CONFIRMATION

Please initial each box to verify that you have read and understand the policies listed below:

I certify that:
	I am the parent or legal guardian of the child(ren) listed in this application and understand that I may have to present documentation to confirm physical custody of the child needing care to be eligible for the AmeriCorps Childcare Benefit Program.
	I need the AmeriCorps Childcare Program benefit in order to serve.
	All information submitted in this application is true and correct and I understand that any misrepresentation or falsification of information may result in prosecution under applicable state and federal law.
	My total family household income has been reported.

I understand that:
	The information on this application and supporting documentation is required to determine my eligibility for the benefit.
	The AmeriCorps Childcare staff may verify any information on this application at any time they deem necessary.
	The childcare benefit for which I may be eligible is based on income, household size, age of child(ren), the provider/program license type, and the provider/programs location. If there are any changes to my situation, I must report all changes to the AmeriCorps Childcare Program immediately.
	I must notify the AmeriCorps Childcare Program if and when my service status changes or ends. I understand that my eligibility ends on my last day of service.
	I must select a qualified childcare provider/program that meets state and federal qualifications necessary to participate in the AmeriCorps Childcare Program. The AmeriCorps Childcare Program is under no obligation to begin payments until the provider/program has met all prerequisites as described in my state’s Childcare Development Fund Plan.
	I must give the AmeriCorps Childcare Program a minimum of 2 weeks’ notice when changing childcare providers/programs and must turn in all necessary paperwork to process such provider. (See Provider Checklist under FORMS on www.americorpschildcare.com ).
	I may use more than one provider (or use a back-up provider); The AmeriCorps Childcare Program will not pay for the same period of care for the same child, to multiple providers.
	The AmeriCorps Childcare Program will only make all payments to my childcare provider. Payments are distributed on a monthly basis, after the month of care has been provided. Payments are processed within 10 business days of receipt of a completed attendance sheet. You, the AmeriCorps Member, are responsible for paying all childcare charges in excess of the childcare benefit amount.
	AmeriCorps members may not claim a childcare benefit from AmeriCorps while also receiving a childcare benefit from another source.
	I understand that accepting childcare support for the same service for the same child may result in prosecution under applicable state and federal law.
	I understand that AmeriCorps is not legally required to make payments to the childcare provider if I refuse childcare services.

I understand/certify that I have read all of the above and understand its content. I also understand that non-compliance with any of the above may result in termination of my participation in the AmeriCorps Childcare Program and that I may be required to re-pay any money paid on my behalf and any misrepresentation of information may result in prosecution under applicable state and federal law.

_________________________________ __________________________ ____________ AmeriCorps Member Name (please print) AmeriCorps Member Signature Today’s Date

OMB No.: 3045-0142 expires 12-31-2021 Page 2 of 2