5 Member Update Form

^{AmeriCorps Childcare Program - Member Update}

Please use this form to notify GAP Solutions of changes to your AmeriCorps Childcare Benefit Application. If you are starting a new term with AmeriCorps you must submit a new AmeriCorps Member Childcare Application.

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.

AmeriCorps Member Information

AmeriCorps Member Name: __________________________________

Member’s National Service Participant ID#: __________

(your NSPID # may be found in the My AmeriCorps Portal)

Change/Update to Childcare Application (check all that applies to you)

	Change of Address		Change of Work Site
	Change in Family Size		Change of Projected Service End Date
	Change in Marital Status		Change in Work Hours of Service
	Change in Household Income		Report Termination/Resignation from Service
	Adding or Removing Child to/from Benefit		New Childcare Provider (A new Provider Application must be submitted)
	Change in hours child needs childcare		Other

Use the explanation of change section below to further describe the changes or updates to your current application on file. Submission of additional forms/supporting documentation relating to the changed indicated above may be required; a Childcare Coordinator will contact you should additional information be needed.

Explanation of Change

Use this space to explain and describe the change(s) indicated above:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

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AmeriCorps Member Confirmation

I affirm that the information provided in this update form (and any supporting documentation I provide) is true, correct and complete to the best of my ability, knowledge, and belief.

________________________________ ______________

AmeriCorps Member’s Signature Date

OMB Control Number.: 3045-0142 expires 12-31-2021