Attachment 14 - AmeriCorps Child Care Benefits Eligibility Application

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14 AmeriCorps Child Care Benefits Eligibility Application (pdf)

Description of Official Form (pdf above)


AMERICORPS Child Care Benefits Eligibility Application

(NOT for use by VISTA Members)

Please Check One:

  • Initial Application
  • Re-determination (Change of information, eligibility criteria, status, etc.)
  • Returning
    • 2nd Yr.
    • 3rd Yr.
    • (AmeriCorps Leaders Only w/ Supporting Documentation)
Please Check One:
  • Regular Full Time (1700 Hours of) Service
    • Duration of Service (# Months)
  • Other (Abbreviated) Full Time Service - Copy of CNCS Approval Must Be Attached.
    • Total # Hours of Service
    • Duration of Service (# Months)
    • Average Hours Per Week

Please Check:

AmeriCorps*National Civilian Community Corps (NCCC)?

  • Yes
  • No

Promise Fellows Program?

  • Yes
  • No

Ed. Award Only Program?

  • Yes
  • No

Section A. Member and Household Information

  1. Member Name
  2. Mailing Address:
  3. Please list all persons residing in your household. Include all children and adults and their relationship to you (i.e., spouse, aunt, mother, father, child, etc.). For children under 13 years of age for whom you are legally responsible, indicate if AmeriCorps CARE benefits will (or may) be used for childcare. Copy of a birth certificate is required for each child using the benefits.

  4. Name of Household Member SSN # Date of birth Relationship to AmeriCorps Member Gender (M/F) If under 13 yrs. Does child need care? (Y/N)
  5. Are you currently receiving publicly subsidized childcare for any children listed in Section 3? ** ??Yes ??No If yes, please specify type of subsidy:
  6. Based on the information provided in Section 3, indicate your family size (including yourself) below: Family Size # of Adults # of Children

Section B. FAMILY INCOME: Enter information for each income source on lines #1-7. Indicate gross monthly or yearly income. Eligibility is based on family's monthly gross income and size. Family must be determined eligible in order to receive child care benefits. Be sure to include gross AmeriCorps living allowance on line #1.

Proof of income must be attached to the application (most recent 4 consecutive weeks) a. Applicant b. Spouse c. Other household or family member d. Other household or family member
Income for Current
Year _______
Income for Current
Month ______
Year ______
Income for Current
Month ______
Year ______
Income for Current
Month ______
Year ______
1. Wages & Salary (gross) includes AmeriCorps allowance
2. Pensions, Retirement, Social Security Benefits
3. Unemployment, Worker's Compensation
4. Public Assistance (i.e. AFDC, TANF)
5. Child Support, Alimony
6. Other:


? Grantee Information Host Site Information
1. Name of AmeriCorps Grantee and Host Site
2. Complete Address (Street, City, State, Zip Code)
3. Telephone Number ( )___-_______ ( )___-_______
4. Fax Number ( )___-_______ ( )___-_______
5. Grantee ID# #
6. Host Site Contact's Name
  1. Host Site's Program Start Date: _____/_____/_____
    Host Site's Program End Date: _____/_____/_____
  2. Member's Service Start Date: _____/_____/_____
    Member's Service End Date: _____/_____/_____
  3. Will the Member be required to work weekends and/or evenings?
    • Yes  (Please attach an authorization letter);
    • No


  1. MEMBER CERTIFICATION: (Please read carefully, sign and date in designated areas)
    I certify that all of the above information is true and correct. I certify that I need child care to be paid for in order to complete my term of service. I understand that this information is being given in connection with federal funds, that agency officials may verify any information, at any time they deem necessary. I understand that deliberate misrepresentation will result in denial of my application or termination of my child care benefits and/or my AmeriCorps service. I also understand that any misrepresentation or falsification of information that is in any way related to the child care benefit, may result in reclaiming from me, any money paid for child care on my behalf and may be punishable under criminal law. In addition, I certify that I am the parent or legal guardian of the child(ren) listed in Section A.3 and that I will be required to submit proof of such, in order to receive child care benefits.
    I have read the above paragraph and understand its content.
    • Member Signature
      • Date
  2. PROGRAM DIRECTOR CERTIFICATION: (Please read carefully, sign, and date in designated areas)
    I certify that the Member listed above and on page 1of this application is eligible to receive child care benefits because s/he meets the following criteria:
      • To the best of my knowledge, the Member is the parent or legal guardian of the child(ren) listed in Section A.3
      • The Member will need child care to be paid for in order to serve in AmeriCorps.
    • Program Director's Name (Please Print)
    • Program Director's Signature
    • Date

Please make copies of all paperwork for your files, mail originals only, and allow 3-4 weeks for processing of accurate and complete paperwork.



Please read carefully and Initial beside each Item*

  • I understand that my state determines income eligibility requirements that will be verified during the application process.
  • I understand that if I am determined income ineligible, I am responsible for any child care costs accrued.
  • I understand that AmeriCorps CARE can only pay up to my state's local market rate for childcare fees.
  • I am a full-time AmeriCorps member.
  • I understand that I must select a legal caregiver, that my state determines who is considered a legal caregiver, and that AmeriCorps CARE cannot reimburse my caregiver unless all state requirements are met.
  • I understand that I must give AmeriCorps CARE a minimum of two (2) weeks notice when changing caregivers by submitting a change of caregiver form and a new caregiver Information and registration form.
  • I understand that I must notify my program director Immediately If plan to resign from AmeriCorps. Final payments to my caregiver cannot be made until I complete a termination of child care benefits form with my program director and submit final coupons (must be correct and complete).
  • I understand that I am not eligible for childcare through AmeriCorps CARE If I am receiving a childcare subsidy from another source, nor will AmeriCorps CARE cover any co-pay on existing childcare subsidies.
  • I understand that AmeriCorps CARE will not reimburse more than one caregiver for the same period of time, for the same child and will only reimburse a maximum of two caregivers at a time. 
  • I understand that my caregiver must meet the minimum age requirement set by my state (18 yrs. Old In most states).
  • I understand that If I use a back-up caregiver, AmeriCorps CARE must reimburse my primary caregiver before reimbursing my back-up caregiver.
  • I understand that AmeriCorps CARE will not reimburse me for childcare and that all reimbursements are made directly to the caregiver.

I have read all of the above and understand Its content. I also understand that non-compliance with any of the above and/or falsification of Information on any AmeriCorps CARE documents will result in termination of my childcare benefits and that In such a case I my be required to re-pay any monies paid on my behalf.

  • Member's Name (please print)
  • Member's Signature
  • Date