AD-2023 Individual Volunteer Program and Service Agreement

Form Approved – OMB No. 0560-0232

OMB Expiration Date: 04/30/2021

AD-2023 U.S. DEPARTMENT OF AGRICULTURE (proposal 1) INDIVIDUAL VOLUNTEER PROGRAM SERVICE AGREEMENT
NOTE:	The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended).  The authority for requesting the information identified on this form is 7 USC 2272.  The information will be used to identify conditions and obtain agreement concerning the acceptance of volunteers who will without compensation, perform services in furtherance of Agency programs.  The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for OPM/GOVT-1 - General Personnel Records.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility for the volunteer to participate in this program.  According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0232. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO THE APPROPRIATE AGENCY.
Volunteer is an individual, group, or organization who sponsors individual's services without compensation, and who performs those services in furtherance of the programs of the Agency.
1. Name of Volunteer
     
2. Home Address (Including Zip Code):
     
3. Telephone Number (Including Area Code):
     
4. Enter a check for applicable Agency: FAS FSA RMA
I understand that my services are on a volunteer basis without compensation or reimbursement for any incidental expenses. I am permitted access to the worksite only during my approved duty hours. I am not considered a Federal employee except for the purposes of the Federal Employees Workers’ Compensation Act and the Federal Tort Claims Act and will not be eligible for health insurance, life insurance, retirement or any other benefits. My service may not be credited for the civil service retirement purposes if I am later employed by the government, though the work may count as experience for qualifications purposes.
I understand that permission must be given by my supervisor before I operate any government equipment or motor vehicle or handle any property, that it may be used for approved, official purposes only, and that I may be held responsible for any unreasonable damage. I am not authorized to represent the agency in any matter or proceeding nor expend government funds. Any inventions made during the assignment must be submitted to your agency for a determination of rights. Prior approval must be obtained prior to publishing the results of any work, study or research.
Further, I understand that I serve under the supervision of a Federal official and that my services may be terminated at any time.
5. I UNDERSTAND AND AGREE TO THE CONDITIONS OF MY SERVICE DESCRIBED ABOVE:
A. Signature of Volunteer						B. Date (MM-DD-YYYY)
						     
6. TO BE COMPLETED BY RESPONSIBLE OFFICIAL:
A. Location (Address)
     
B. Brief description of duties:
     
C. Effective Date (MM-DD-YYYY)				D. Fiscal Year
     				     
E. Responsible Official Signature			F. Title			G. Date (MM-DD-YYYY)
			     			     
7. TERMINATION OF AGREEMENT:
A. AGREEMENT TERMINATED ON (Month, Day, Year )		B. SIGNATURE OF RESPONSIBLE OFFICIAL			C. SIGNATURE OF VOLUNTEER/STUDENT
     

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.