Form 1 Ed Award Commitment Matching Form

Segal AmeriCorps Education Award

Matching Program

Commitment Form

Program Purpose: The Segal AmeriCorps Education Award Matching Program provides colleges and universities that match the Segal AmeriCorps Education Award an opportunity to be listed on the Corporation for National and Community Service (CNCS) Website. By participating in the program, colleges and universities benefit by attracting AmeriCorps alumni to enroll in their higher education institutions. AmeriCorps alumni have the traits and skills colleges and universities values, such as a commitment to community, problem-solving experience, and training as leaders. Colleges and universities that offer match to the Segal AmeriCorps Education Award make education more affordable to AmeriCorps alumni who have served their country in local communities across the United States. CNCS encourages all colleges and universities to participate in this program; however, it is not mandatory.

Section I: Profile Information

Name of Higher Education Institution: _____________________________________

If the Segal AmeriCorps Education Award Matching Program applies to a specific department or school, please list here:

______________________________________________________________________

Website: _____________________

City, State: ___________________________________________________________

Primary Contact:

Name: _____________________

Phone: ______________________

Fax: ________________________

E-mail: ______________________

Mailing Address: ______________________

President, Provost, or Dean that is signing Commitment Form:

Name: _____________________

Phone: ______________________

Fax: ________________________

E-mail: ______________________

Institution Profile:

Type (please check one):

Public ____ Private _____

Program Types (check all that apply):

2 Year ___ 4 Year ___ Graduate ____

Is Your Institution Eligible to Award Federal Student Aid Funds Based on (check all that apply):

Title IV___ VA Qualified ____

Is Your Institution (check all that apply):

Faith-Based ______ Historically Black College/University _____

Tribal College _____ Hispanic Serving Institution ______

Section II: Commitment Level

Provide a detailed description of what your institution is offering for the Segal AmeriCorps Education Award Matching Program. This language will be posted on our website (www.nationalservice.gov ) and should clearly outline your institution’s commitment to AmeriCorps alumni. Include the amount of the dollar match along with any additional benefits that your institution will offer to AmeriCorps alumni.

Please note: Educational institutions must provide a minimum match of $1,000 to be listed on the CNCS website. A dollar for dollar match is the preferred level of commitment from schools that participate in this program.

Percentage of the award that your institution will match for an admitted AmeriCorps alumni: ________%.

Refer to FAQs for an explanation and current amount of the Segal AmeriCorps Education Award. (link to FAQs sheet). The Segal AmeriCorps Education Award is tied to the maximum amount of the U.S. Department of Education’s Pell Grant.

To qualify under the Segal AmeriCorps Education Award Matching Program, AmeriCorps alumni must have successfully completed their full term of service. *Refer to FAQs for a listing of programs and required hours.

*VISTA Summer Associates and AmeriCorps alumni who did not complete service and did not terminate for compelling reasons are not eligible for this program.

Section III: Commitment Timeframe

This commitment to the Corporation for National and Community Service is valid for five (5) years from the date of signature on this agreement. This agreement will be up for renewal on _________, 2017.

If the institution needs to terminate this agreement, CNCS will be notified to in order to delete the website listing; otherwise students will continue to contact the institution.

CNCS reserves the right to delete the website listing for any institution not in compliance with the Segal AmeriCorps Education Award Matching Program requirements.

Please return this form to: INSERT EMAIL ADDRESS

OR

Fax: 202.606.3475

Ph: TBD

OMB Control Number: TBD  Expiration Date: TBD

Public Burden Statement: Public reporting burden for this collection of information is estimated to average 30 minutes per submission, including reviewing instructions, gathering and maintaining the data needed, and completing the form. Comments on the burden or content of this instrument may be sent to the Corporation for National and Community Service, Attn: Amy Borgstrom, 1201 New York Avenue, NW, Washington, D.C. 20525. CNCS informs people who may respond to this collection of information that they are not required to respond to the collection of information unless the OMB control number and expiration date displayed on page one are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)

Privacy Act Notice: The Privacy Act of 1974 (5 U.S.C § 552a) requires that the following notice be provided to you: The information requested on the Segal Education Award Matching Commitment Form is collected pursuant to 42 U.S.C 12592 and 12615 of the National and Community Service Act of 1990 as amended, and 42 U.S.C. 4953 of the Domestic Volunteer Service Act of 1973 as amended. Purposes and Uses - The information requested is collected to evaluate applications for the childcare subsidy made available to AmeriCorps members by law, and to evaluate applications to provide the childcare. Routine Uses - Routine uses may include disclosure of the information to federal, state, or local agencies pursuant to lawfully authorized requests. In some programs, the information may also be provided to federal, state, and local law enforcement agencies to determine the existence of any prior criminal convictions. The information may also be provided to appropriate federal agencies and Department contractors that have a need to know the information for the purpose of assisting the Department’s efforts to respond to a suspected or confirmed breach of the security or confidentiality or information maintained in this system of records, and the information disclosed is relevant and unnecessary for the assistance. The information will not otherwise be disclosed to entities outside of AmeriCorps and CNCS without prior written permission. Effects of Nondisclosure - The information requested is voluntary.