AD-2024 Sponsored Volunteer Program Service Agreement

Form Approved - OMB No. 0560-0232 OMB Expiration Date: 04/30/2021
AD-2024 U.S. DEPARTMENT OF AGRICULTURE (proposal 1) SPONSORED 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 allow a group or organization to identify and sponsor 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 group or organization 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.
If the volunteer is sponsored by a group or organization, that group or organization must complete this agreement before volunteer begins services.
1. NAME OF SPONSOR/ORGANIZATION (Print)
     
2. ADDRESS (Street, City, State, Zip Code)						3. TELEPHONE NUMBER (Include Area Code)
     						     
4. DUTY STATION (Address)					5. SELECT AGENCY WORK IS TO BE PERFORMED (Choose only one)
     					FAS FSA RMA Complete a separate form for each Agency.
6. DESCRIPTION OF WORK TO BE PERFORMED:
     
7. The above‑described work will be contribute to what is identified in Item 6. Except as provided below, the work performed by the participants will not confer on them or on our employees or officers the status of federal employees.
8. We will provide the Agency with a listing of participants and hours and days contributed to accomplish the work in Item 6 above.
9. We will obtain parental or guardian consent for each individual under 18 years of age and will comply with child labor laws.
10.	     			is hereby designated to serve as our liaison with the Agency identified
in Item 5 in day‑to‑day operations under this agreement.
11. We understand that the Agency identified in Item 5 or we, may cancel this agreement at any time by notifying the other party.
12A. SIGNATURE OF SPONSOR/ORGANIZATION								12B. DATE (MM-DD-YYYY)
								     
13. Agency identified in Item 5 acceptance of services described below:
A. Provide such materials, equipment, and facilities as are available and needed in performing the work described above.
B. Incidental expenses, such as transportation and meals may be paid by the Agency when these expenses are related to the performance of work for the Agency.
C. Consider sponsored participants as federal employees for the purpose of tort claims and compensation for work injuries, to the extent not covered by the sponsor. Authorization by Pub. L. 97‑98.
D. Authorize sponsored participants to operate federal motor vehicles when necessary provided the individual holds a valid state driver’s license.
14A. SIGNATURE (Agency)			14B. TITLE				14C. UNIT		14D. DATE (MM-DD-YYYY)
			     				     		     

AD-2024 (proposal 1) Page 2 of 4
15. REMARKS
     
16. The Sponsor/Organization desire to make available the volunteer services of the following person(s) to assist with the Agency identified in Item 5.
A. Volunteer 1:
(1) Name of Volunteer (First, Middle, Last)	(2) Home Address		(3) Telephone No. (Include Area Code)
     	     		     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)		(6) Fiscal Year
     		     
B. Volunteer 2:
(1) Name of Volunteer (First, Middle, Last)	(2) Home Address		(3) Telephone No. (Include Area Code)
     	     		     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)		(6) Fiscal Year
     		     

AD-2024 (proposal 1) Page 3 of 4

C. Volunteer 3:
(1) Name of Volunteer (First, Middle, Last)	(2) Home Address			(3) Telephone No.(Include Area Code)
     	     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)			(6) Fiscal Year
     			     
D. Volunteer 4:
(1) Name of Volunteer (First, Middle, Last)	(2) Home Address			(3) Telephone No. (Include Area Code)
     	     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)			(6) Fiscal Year
     			     
E. Volunteer 5:
(1) Name of Volunteer (First, Middle, Last)	(2) Home Address			(3) Telephone No. (Include Area Code)
     	     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)		(6) Fiscal Year
     		     
F. Volunteer 6:
(1) Name of Volunteer (First, Middle, Last)	(2) Home Address			(3) Telephone No. (Include Area Code)
     	     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)		(6) Fiscal Year
     		     

AD-2024 (proposal 1) Page 4 of 4

G. Volunteer 7:
(1) Name of Volunteer (First, Middle, Last)		(2) Home Address			(3) Telephone No. (Include Area Code)
     		     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)			(6) Fiscal Year
     			     
H. Volunteer 8:
(1) Name of Volunteer (First, Middle, Last)		(2) Home Address			(3) Telephone No. (Include Area Code)
     		     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)			(6) Fiscal Year
     			     
I. Volunteer 9:
(1) Name of Volunteer (First, Middle, Last)		(2) Home Address			(3) Telephone No. (Include Area Code)
     		     			     
(4) Duties to Perform
     
(5) Effective Date (MM-DD-YYYY)			(6) Fiscal Year
     			     
17. 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.