4 Award Transfer Revoke Form

NATIONAL SERVICE TRUST

Request to Revoke Transfer of Education Award (#12)

Use this form if you wish revoke all or a portion of an education award amount that you transferred. You may revoke any unused transferred award amount at any time prior to its expiration and for any reason. The funds will be credited to your account unless your award has expired. You must make a separate revocation for each award amount that you transferred. Select the Help button for additional information on award transfer criteria and constraints.

[Your NSP ID/SSN] [your name]

Select transfer award term of service [Transferred award amount] amount you wish to revoke

[Award transfer recipient] [NSP ID]

[Address]

[email]

I revoke the amount stated of the award transferred to the recipient named above.

I certify that all of the information I have provided above is true and correct to the best of my knowledge.

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, U.S.C.., exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result of my program participation, or other actions authorized by the Civil Fraud Remedies Act, 31U.S.C. 3801-3812.

Submitting this form electronically constitutes your signature

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. This form is used by AmeriCorps members to revoke an education award amount previously transferred to a qualified recipient and 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 CNCS 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. 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- 0136 Expiration 8/31/2017