Form 2 2010 Summer of Service Enrollment and Exit

6/7/2010, 10:18 AM, EDT

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* First Name:
Middle Name:
* Last Name:
* Social Security Number:
* Date of Birth:
* Gender:
* Address:

* City:
* State:
* Zip code:

-

* Last completed grade level
* Does this student receive free or
reduced lunch?:

Yes
No

Student Phone:
* E-Mail Address:
Parent/Legal Guardian Information
* First Name:
* Last Name:
* Parent/Guardian Address:

* City:
* State:

(click here to copy student address)

* Zip code:

-

Phone:
* E-Mail Address:
Placement Information
* Program Title:

Select
Select

* Hours of Service Performed:
* Start Date:
* End Date:
Certification
I CERTIFY TO THE FOLLOWING:
This student

has met the applicable eligibility requirements for the approved summer of service position,
as appropriate, in which the individual serverd.
has successfully completed the required term of 100 hours of service during the summer
months in the approved national service position, as certified through a process determined
by the Corportation.
is a citizen or national of the United States or lawful permanent resident alien of the United
States.
has not already earned two Summer of Service Education Awards.
completed service hours that did not include any service activities that were prohibited by
law, regulation, or grant provision.

*

✔

I, ______, certify this form as of 06/07/2010.

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, U.S.C.,
exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result
of my enrollment or other actions authorized by the Civil Fraud Remedies Act.
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Last updated: Tuesday, May 25, 2010, 02:43 PM
Release version: 4.3

OMB Number: 3045–0006 (Enrollment) and 3045–0015 (Exit)
Public Burden Statement: The Paperwork Reduction Act of 1995 requires the Corporation to inform all potential persons who are to
respond to this collection of information that such persons are not required to respond unless it displays a currently valid OMB
control number. (See 5 CFR 1320.5(b)(2)(i)).
Time Burden: The time required to complete this collection of information is estimated to average 10 minutes per participant.
Use of Information: The information collected constitutes an application for benefits.
Effects of Non-Disclosure: Providing this information is voluntary; however, failure to provide the information would not allow the
Corporation to assess the applicant’s request for benefits.
In this case, it will not be possible to consider allocating benefits
to the applicant.
Privacy Act:
purposes.

Information provided for this collection may be shared with federal, state, and local agencies for law enforcement