3 Childcare Attendance Sheet

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 Childcare 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 Name: _______________________________________________

Member E-Mail Address: ____________________________________

Provider Name: ____________________________

___

Provider E-Mail Address: ___________________________________

Month of Care: _______________________________________________

Year of Care: ______________________________ State: __________

CHILDREN IN CARE:
Child Name

Age

Childcare Provider Rate (Ex: $100/weekly)

1.
2.
3.
Instructions: Fill in the total # of hours each day care was provided (Ex: If care was provided from 8am-5pm you
would write “9” in the box below). Please use the letter “A” for absent/sick,“H” for holidays, and “W” for weekends.
Days of the Month

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

Child 1:
Child 2:
Child 3:
Days of the Month

Child 1:
Child 2:
Child 3:

INVOICE CHARGES: Please fill in the weekly charges and add up the total for the month
WEEK 1

$

WEEK 2

$

WEEK 3

$

WEEK 4

$

WEEK 5

$

TOTAL INVOICE CHARGES

$

I certify that the information and attendance record entered on this attendance sheet are true and accurate. I understand that my payment will be in
accordance with the CCDF Block Grant program guidelines for my state. I further understand that any misrepresentation of information may result in legal
action.

X
Childcare Provider Signature

Date

AmeriCorps Member Signature

Date

X
*Upon receipt of a completed Attendance Sheet, payment will be made within 10 business days
(Incomplete attendance sheets will NOT be processed)
OMB Control Number: 3045-0142 expires 12-31-2021

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