4 2010 AC Exit Form

For Official Use Only

	National Service Trust Exit Form
	This form will end the term of a serving member in the National Service Trust and report on the eligibility of the member for an education award. It will also provide the Corporation with evaluation exit data.

PART 1 Member: Please Complete and Sign

1.

Name

Last

First

MI

2.

Social Security Number

3.

Mailing Address (Where the education award should be sent, if mailed)

Number and Street

City

State

Zip Code

Email Address

Home Phone

B usiness Phone

E xt

4. For VISTA Volunteers only: I would like to

Extend my service for less than a year	Reenroll for another year
Complete my service as scheduled	Terminate my service early

5. Post Service Opportunities:

The Corporation for National and Community Service would like to encourage you to stay involved in service and help you connect with educational, professional, and alumni opportunities. If you are interested in staying connected with the following organizations, please let us know.

Yes, I give the Corporation for National and Community Service permission to release my name, address (including e-mail), and telephone number to the following types of organizations:

• Educational institutions that are interested in recruiting former AmeriCorps, Silver Scholar, or Serve America Fellow program members or that provide special programs for former members

• Organizations offering professional development opportunities or staff positions to AmeriCorps, Silver Scholar, and Serve America Fellow program members

• AmeriCorps, Silver Scholar, and Serve America Fellow program Alumni organizations

• Organizations that sponsor service opportunities and want to recruit former AmeriCorps, Silver Scholar, or Serve America Fellow program members

I am particularly interested in the following issue areas (please mark all that apply):

	Education		Public Safety		Housing		Health
	Natural & Other Disasters						Infrastructure Improvement
	Environmental Stewardship & Conservation						Energy Conservation
	Urban & Rural Development						Faith & Community Based

No, please do not share my information with other organizations

Certification of Service:

I certify that the time I reported as program service hours is true and correct and did not include any service activities prohibited by law, regulation, or grant provisions. I agree, by signing this form, to provide, if asked, documentation to verify the accuracy of the information I have provided in this form.

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 participation in this program; or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

M ember's Signature: Date:

Privacy Act Statement -- 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. The primary purpose of the information is to obtain from AmeriCorps program representatives their determination of whether a member successfully completed a term of service and is eligible to receive an education award. The evaluative information will help the Corporation improve its programming and services to members. For individuals who have indicated their desire to receive additional information on alumni organizations or special educational opportunities for alumni, members' names, addresses, and phone numbers will be shared with those organizations for that purpose. 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 in the year it is used. Your Social Security Number (SSN) is solicited under the authority of the Internal Revenue Code (28 U.S.C. 6011(b) and 6109), for use as a taxpayer identification number. Failure to disclose the SSN or any other information may result in a denial of your receiving an education award or it may delay the processing of your education award.

OMB No.: 3045-0015 Expires:

Exit information should be electronically submitted to the Corporation within 30 days of completion of service.

PART 2

Certifying Official: Please Complete and Sign

This section must be signed by an authorized certifying official. The program must designate certifying officials electronically to the Corporation for National and Community Service.

1. N ame of Program or AmeriCorps*NCCC Campus

2. O perating Site I.D. Number

3. H ours of Service Performed

(not applicable for VISTA) Hours

4. D ate of Completion of Term of Service

Month Day Year

5. Type of Enrollment

(Mark only one.)

Full-time (1700 hours per year or 365 days for VISTA)

Half-time (900 hours in up to 2 years)

Reduced half-time (675 hours)

Quarter time (450 hours)

Minimum time/Summer (300 hours)

Silver Scholar (350 hours min)

6. Education Award Status:

Indicate whether or not the Member is eligible for an education award. Please be sure to follow the Corporation's regulations in making this selection. If the Member is going to serve another term under the National Service Trust, a new National Service Enrollment Form must be completed.

Eligible for entire education award (member successfully completed service)

Eligible for partial education award (member did not fully complete service for compelling personal reasons)

Not eligible for education award (member did not fully complete service requirements)

Not eligible for education award (member chose alternative benefit)

Not eligible for education award (member dismissed for misconduct)

Not eligible for education award. Other (Specify):

Did the member perform satisfactorily (complete all assignments, tasks, and projects)? Yes No

7. Certification of Service

I certify that to the best of my knowledge and belief, the time the above-listed member reported as AmeriCorps, Silver Scholar, or Serve America Fellow program service hours did not include any service activities prohibited by law, regulation, or grant provision;

That the member performed satisfactorily (completed all assignments, tasks, and projects); and

That the hours of service performed indicated on this form for this service member are true and accurate.

I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001of Title 18, U.S.C. or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

S ignature of Certifying Official: Date:

N ame of Certifying Official (Please Print):

Public reporting burden -- Estimated time to complete this form, including time for reviewing instructions, gathering, and providing the information needed to complete the form is 3 minutes for the Member section and 4 minutes for the Certifying Official section. Send comments regarding this burden or the content of this form to: Corporation for National and Community Service, National Service Trust, 1201 New York Avenue, NW, Washington, DC 20525. The Corporation informs the potential persons who are to respond to this collection of information that such persons are not required to respond to the collection of information unless it displays a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1)).

For Official Use Only