Form 1 2007 Revised Voucher

AMERICORPS - VOUCHER AND PAYMENT REQUEST FORM

for AmeriCorps Member: Firstname Lastname SSN: 000-00-0000

Section A - TO BE COMPLETED ONLY BY AMERICORPS MEMBER - The AmeriCorps member must fill out the four items in Section A. A SEPARATE voucher must be completed for each payment authorized/requested. Then the member must send the voucher to the school or loan holder.
AWARD INFORMATION as of (date) Balance of First Award: $ 2,362.50 Valid Until: 2/1/2005 Balance of Second Award: $ Valid Until Current Balance in Account: $ 2,362.50	(1) Enter the amount you request and authorize to be taken from your account. Please initial any changes. $ _________________ (2) If this payment is for current education expenses give the semester or term ___________________ ( term)
I certify that I have not been convicted, since the completion of my AmeriCorps service, of the possession or sale of a controlled substance. I further certify that I have received either a high school diploma or its equivalent (such as a GED). I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or imprisonment or both under Section 1001 of Title 18, USC; exclusion from participation in Federal programs; forfeiture of benefits I may receive as a result of my enrollment; or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3802. (If you are unable to make this certification, please write to the National Service Trust to find out what you must do to be eligible to use your award). I authorize the amount indicated above to be paid to the loan holder or educational institution named in Section B. I further authorize the release of any account information to the National service Trust. (3) Signature of Member _______________________________________________ (4) Today’s date: _______________ .

Section B - TO BE COMPLETED ONLY BY SCHOOL OR LOAN HOLDER - The school or loan holder must complete and sign Section B. Fill out the appropriate portion depending upon whether the voucher is to repay a qualified student loan or to pay for current educational expenses. Include the complete address where the payment should be sent. Send the completed voucher to the address below to receive payment. See “Guidelines & Uses” sent to students with this voucher. Do not reuse processed vouchers.
If payment is for a QUALIFIED STUDENT LOAN, loan holder must complete this section. A qualified student loan for the purposes of the education award is: a loan made, insured, or guaranteed pursuant to Title IV of the Higher Education Act of 1965, other than a loan to a parent of a student pursuant to section 428B of such Act; any loan made pursuant to Title VII of VIII of the Public Health Service Act; or a loan determined by an institution of higher education to be necessary to cover a student’s cost of attendance at such an institution and made, insured, or guaranteed directly to the student by a state agency. 1. Loan name and number (If a Federal Consolidation Loan, please include “federal” in the loan name): ___________________________________ 2. Payoff amount (add 30 days interest): $________ 3. If a state agency-made loan, name of the agency: ___________________________________________ The organization listed below is the holder of the loan (which is defined as the original lender or another person or organization to which the loan was subsequently sold, transferred, or assigned and which has a legally enforceable right to receive payment from the borrower).	If this payment is for CURRENT EDUCATIONAL EXPENSES, the Title IV school must complete this section. 1. The Cost of Attendance less any other student aid, or comparable allowed amount for non-degree programs (NOT just the AmeriCorps education award amount). This is the amount the student is eligible for. The total of all student aid, including the education award, cannot exceed the CoA or the comparable amount allowed for non-degree programs. . $________ 2. School enrollment period upon which this amount is based. For amounts exceeding $1500.00, payment is made in two equal installments; one at the beginning and one at the middle of the enrollment period. enrollment start date___________ enrollment mid point date ____________ (1st installment) (2nd installment) 3. Title IV School Code (6 digits): _____________ The individual named above is a student enrolled at the institution listed below, which has in effect a Title IV Program Participation Agreement with the U.S. Department of Education. Eligibility to participate in any of the Title IV programs has not been limited, suspended, or terminated. Further, the number of students using an award in the current academic year is not more than 15% of the total student population.
Name of School or Loan Holder (Payee): __________________________________________________________________ Address_______________________________________________________________________________________________ City____________________________________________ State _________ Zip Code _____-____ Federal Taxpayer ID Number (9 digits): _____________________________ Customer Service eMail: ____________________________________________________
I certify that all of the information I have provided above is true and correct. I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001 of Title 18, USC. ________________________________________________________________________ ______________________________ ______________________________ Full signature of authorized representative of the school or loan holder Phone Number (including area code) Fax Number Printed or typed name of representative________________________________________ Dept. _________________________ Date __________________
MAIL VOUCHER TO: NATIONAL SERVICE TRUST/CNCS; 1201 NEW YORK AVENUE NW, WASHINGTON, D.C. 20525

PRIVACY ACT NOTICE-In compliance with the Privacy Act of 1974, the following information is provided: The collection of this information is authorized by the provisions of the National and Community Service Act of 1990, as amended. This form is used by AmeriCorps members to request a payment from their education award accounts, by schools or lenders to verify eligibility for the payments, and by both parties to verify certain legal requirements. Information may also be provided to federal, state, and local agencies for law enforcement purposes. Information will not otherwise be disclosed outside the Corporation without written permission. The Internal Revenue Service has determined that the education award is taxable income in the year it is used. Failure to disclose the Social Security Number or any other information may result in the payment being delayed or denied.

PUBLIC REPORTING BURDEN - Estimated time to complete this form, including time for reviewing instructions and gathering & filling in information is 5 minutes. Send comments regarding this burden or the content of the form to the National Service Trust at the address listed above. Respondents are not required to fill out this form unless it displays a valid OMB control number on this page. (See 5 CFR 1320 5(b)(2)(b)). OMB Number 3045-0014