Form 2 2010 Voucher and Payment Request Form

NATIONAL SERVICE TRUST VOUCHER AND PAYMENT REQUEST FORM

for Segal Education Award Recipient: Firstname Lastname SSN: 000-00-0000

PART A: to be completed ONLY by the AMERICORPS, SILVER SCHOLAR, SUMMER OF SERVICE, or SERVE AMERICA FELLOW Program Member, or award transfer recipient. The member must complete a SEPARATE voucher for each payment requested and forward it to the school or loan holder.
AWARD INFORMATION as of (date) Balance of First Award: $ 0000.00 Valid Until: Balance of Second Award: $ 0000.00 Valid Until: Balance of Third Award: $ 0000.00 Valid Until: Current Balance in Account: $ 0000.00	(1) Enter the amount you authorize to be taken from your account $ ______________ (2) If this payment is for current education expenses give the semester or term ___________________ Payments to VA Approved Programs must be from an award earned in a FY2010 program or later and an enrollment starting on or after 10/1/2009. Transferred award amounts may not be included in payments for a Veterans Affairs approved program, unless it is also a Title IV school. If you wish your loan payment to be credited against one particular loan please call your loan holder after the Trust has processed the payment.
I certify that I have not been convicted, since the completion of my term of service, or receipt of my transferred award amount, of the possession or sale of a controlled substance. (If you are unable to make this certification, please contact the National Service Trust to find out what you must do to be eligible to use your award). 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. I authorize the amount indicated above to be paid to the loan holder or educational institution named in Section C. I further authorize the release of any account information to the National service Trust. (3) Signature of Member _______________________________________________ (4) Today’s date: _______________

PART B: to be completed ONLY by the EDUCATIONAL INSTITUTION or LOAN HOLDER. 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 National Service Trust address below to receive payment. See “Guidelines & Uses” sent to students with this voucher. Do not reuse processed vouchers.

B.1 LOAN PAYMENT REQUEST SECTION: the 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. * indicates a mandatory field.

1. *Loan Number: __________________________ 2. *Payoff amount (add 30 days interest): $ ____________________

3. *Federally Guaranteed Loan Name:_____________________________

4. If a state agency-made loan, name of agency: _________________________

The organization named 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).

B.2 CURRENT EDUCATIONAL EXPENSES SECTION: the Title IV school or the institution eligible to receive GI Bill educational benefits must complete this section.

The member named in Part A is a student enrolled in the institution named in Part B, which has in effect a Title IV Program Participation Agreement with the U.S. Dept of Education or is one eligible to receive GI Bill education benefits, or both. 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. “Current” means expenses incurred during or after the member’s term of service in AmeriCorps.

1. The Cost of Attendance $________

less any other student aid or comparable allowed amount for non-degree programs. 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. Veteran’s benefits may not be included in CoA calculation for AmeriCorps payments. Please do NOT simply state the Education Award balance.

2. School enrollment period upon which this amount is based: enrollment start date___________ enrollment mid point date ____________ (both dates mandatory)

(1^st installment) (2^nd installment)

For amounts exceeding $10.00, payment is made in two equal installments; one at the beginning and one at the middle of the enrollment period unless that period is in the past or within 10 days of the scheduled payment date.

3. Title IV School Code (6 digits): _____________

4. If an education or job training program approved by the Secretary of Veteran Affairs: Check here 

The institution named below certifies that the amount requested will be used to pay all or part of the member’s expenses attributable to a course or program of education, apprenticeship, or job training offered by that institution, and that the course or program is currently approved by the Secretary of Veterans Affairs or the designated state approving agency for the state where the institution is located. Note that transferred award amounts may not be used to make payments for this purpose. Refunds of any education award amounts must be made to the National Service Trust. Please enter VA (School) Facility Number: _____________________

B.3 Name of School or Loan Holder (Payee): __________________________________________________________________

Address_______________________________________________________________________________________________

City____________________________________________ State _________ Zip Code _____-____

Federal Taxpayer ID Number (9 digits): _____________________________ Customer Service e-Mail: ____________________________________________________

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 or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812

________________________________________________________________________ ______________________________ ______________________________

Full signature of authorized representative of the educational institution 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

or fax to 202 606 3484

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, the National & Community Service Trust Act of 1003, and the Serve America Act of 2009. This form is used by award recipients to request a payment to 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