Form_REDLINED_2019-2023

AmeriCorps Member Disability Accommodation Off Set Reimbursement Request Form

Overview
Grantee organizations are responsible for providing reasonable accommodations for their AmeriCorps members. The funds that AmeriCorps State and National provides toward accommodation are intended to offset a grantee’s costs and the pool of funds is awarded on a first come, first serve basis.

Because a member may be sensitive about the request to disclose their need or reason for an accommodation, the information requested on this form, which might identify the member, should only be used and disclosed to process this reimbursement request, for aggregate reporting, and other crucial reasons which are legally permitted.  The authority for this reimbursement request includes the National and Community Service Act of 1990, as amended (42 USC 12501 et seq., see specifically sections 12592 and 12639).  Please see the Instructions for further information about this form.

Due Date
Requests must be submitted by August 1, 2023.

Instructions
Please provide all the requested information and a receipt to ensure timely processing of your request. Requests are incomplete unless a receipt is attached.

1. Name of Grantee/Subgrantee:
   
   
   

2. Grant Number:

3. Prime Grantee/National Direct/Native Nation Organization Single Point of Contact Name for Request:
   
   
   

4. Prime Grantee/National Direct/Native Nation Single Point of Contact Email Address:
   
   
   

5. Prime Grantee/National Direct/Native Nation Single Point of Contact Telephone Number:
   
   
   

6. Attention to and address to which the check should be remitted:
   (Important note: The prime applicant must indicate knowledge and approval of the accommodation reimbursement request. All payments will be made to the prime grantee only.)

7. Member National Service Participant ID (NSPID) number(s):
   
   
   

8. Type of Disability:
   
   
   

9. Type of Accommodation:
   
   
   

10. Please provide a brief statement as to how the accommodation helps the member(s) achieve full participation in their service assignment(s):
    
    
    

11. What organization and outside community resources were consulted in securing funding for or arranging accommodation, such as coordinating with the Department of Vocational Rehabilitation? Please describe:

12. Requested Reimbursement Amount: $
    
    
    

13. Is this a one-time reimbursement request or a quarterly request for multiple reimbursements?
    One-time _____ Quarterly _____
    Please batch multiple requests into quarterly submissions with an itemized summary.

14. If this is not a one-time request and you foresee batching receipts on a quarterly basis, what is your projected cost for the fiscal year for this member (please provide cost, not a range): $___________

Submitting the Request
The completed request form and receipt must be submitted via secure, encrypted email to Accommodations@cns.gov with organization name and the NSPID in the email subject line.

Reimbursement Process
Reimbursement payments will be made on a first-come, first-served basis until funds are exhausted once a completed request form is submitted with attached receipts.

PUBLIC BURDEN STATEMENT: Public reporting burden for this collection is estimated to average 20 minutes per submission, including reviewing instructions, gathering and maintaining the data needed, completing the form, and reviewing the collection of information. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, Attn: Amy Borgstrom, 250 E. Street SW, Washington, D.C. 20525. You are not required to respond to the collection unless the OMB control number and expiration date displayed on page 1 are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)

Last revised: January 2023 OMB Control No. 3045-0179 Expiration Date: X/XX/XXXX