Form 1 Interest Payment Form

NATIONAL SERVICE TRUST INTEREST PAYMENT FORM

Upon successfully completing a term of service in an AmeriCorps State or National, Silver Scholar, or Serve America Fellow Program (but not a Summer of Service Program) and earning an education award, the National Service Trust will pay, on behalf of the borrower, all or a portion of the interest that accrued on a qualified student loan* during the member’s term of service. The loan must have been in forbearance, Payment will be made only to the loan holder. This payment, like payments from a member’s education award, is considered taxable income in the year the payment is made.

INSTRUCTIONS

FOR THE MEMBER: Fill out the Member Section, send the completed and signed form to each loan holder. Your service period runs from the date you began your service to the date you completed it. Contact your project director if you do not know these dates. Incorrect service dates may delay processing your payment request.

FOR THE LOAN HOLDER: Complete the Loan Holder Section and return the form to: National Service Trust/CNCS, 250 E Street, SW, Washington, DC 20525.

Member’s name:	Social Security Number: ________________________
Street:	Phone:
City, State & zip:
Period of Service (dates): Beginning ________________________________ through ___________________________________ payment cannot be made without dates Mo Day Year Mo Day Year
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 release of any loan information to the National Service Trust. Borrower's signature: ___________________________________________________________________ Date: __________________________

B. LOAN HOLDER’S SECTION: Complete appropriate section, indicating either total $ amount OR daily amount of interest

Cite loan numbers: ___________________________ Payoff amount: $ ________________ Fed Guaranteed Loan name: _____________________ If state agency made loan, name of agency: __________________________	Total amount of interest accrued on member’s qualified loan(s) during service period: $ ________________________ DO NOT include interest which has been or will be paid by the US Dept of Education. DO include all other accrued interest for which the borrower is responsible. ********** OR ********** Daily interest accrual amount: $ ____________ Indicate any period of time within the service period during which interest has been or will be paid by the US Dept of Education. Cite a period only if it is one during which the borrower is NOT responsible for interest, such as a grace period for a subsidized loan: ----------------------------------------------
Loan Holder/Servicer information (where payment should be sent). Address must be complete and legible: Phone: ________________________________ Name: Fax: ________________________________ : Address: Federal Taxpayer ID: __________________________________ Customer Service email: ____________________________________
I certify that the amount designated is for eligible interest that accrued on the qualified student loan(s)* during the service period indicated, and that any loan cited was in forbearance, deferment, a grace period, or in-school status during the service period. 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 action authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812 ____________________________________________________________ __________________________________________________ _____________________________ Signature of Representative of Loan Holder/Servicer Printed Name of Representative Date

* A QUALIFIED STUDENT LOAN is 1) any loan made, insured, or guaranteed pursuant to Title IV of the Higher Education Act of 1965, as amended, other than a loan to a parent of a student pursuant to § 428B of such Act; 2) any loan made pursuant to Titles VII or VIII of the Public Health Service Act; and 3) any 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 directly to a student by a state agency. Examples of these loans include Federal Family Education Loans (Subsidized & Unsubsidized Stafford Loans, Supplemental Loans to Students (SLS), Consolidation Loans), Federally Insured Student Loans (FISL), Federal Direct Loan Program Loans (FDLP), Perkins Loans, Health Education Assistance Loans (HEAL), Health Professions Student Loans (HPSL), Loans for Disadvantaged Students (LDS), Nursing Student Loans (NSL), Primary Care Loans (PCL), and loans made directly to members by a state’s Higher Education Authority and a state institution of higher education. (The ‘maker’ of every loan should be cited on the loan’s Promissory Note.)

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 enable an AmeriCorps member to have a payment made for all or a portion of the interest that accrued while the member was enrolled in the National Service Trust. The form asks the member’s loan holder to inform the Trust of the amount of interest that accrued in order for a payment to be made. Information is for official use only. Your Social Security Number (SSN) is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011(b) and 6109), for use as a taxpayer identification number; disclosure is MANDATORY because the Internal Revenue Service has determined that the education award is taxable income in the year it is paid. Furnishing all other information on this form is voluntary, but failure to do so may result in a denial of your interest being paid or it may delay the payment.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including reviewing instructions, gathering and providing the information needed to complete the form. Send comments regarding this burden or content of this instrument to: Corporation for National and Community Service, National Service Trust, 250 E Street, SW, Suite 300, Washington, DC 20525. The Corporation informs the potential person(s) 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 5 C.F.R. 1320.5(b)(2)(I)).

OMB Number 3045-0053