Mrp 126b Volunteer Service Agreement

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 0579-XXXX. The time required to complete this information collection is estimated to
average 0.5 hours 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
MARKETING AND REGULATORY PROGRAMS

OMB Approved
0579-XXXX
EXP. Date XX/XXXX

VOLUNTEER SERVICE AGREEMENT

PRIVACY ACT STATEMENT:
Collection and use are covered by Privacy Act System of Records OPM/GOVT-1 and USDA/OP-1, and is consistent with the provisions of The Privacy Act of 1974, 5 U.S.C 552a,
which authorizes acceptance of the information requested on this form. The data will be used to maintain official records of volunteers of the USDA for the purposes of tort claims
and injury compensation. Furnishing this data is voluntary; however, if this form is incomplete, enrollment in the program cannot proceed.
NON-DISCRIMINATION STATEMENT:
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 How to File a Program Discrimination
Complaint 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.
This agreement addresses the acceptance of volunteer service under Title 7, U.S. Code, Section 2272. It also serves as a record of such service.

SECTION I – PERSONAL DATA
NAME (Print Last, First, Middle)

HOME PHONE NUMBER

ADDRESS (Include City, State, and ZIP)

MOBILE NUMBER
EMAIL ADDRESS

CITIZENSHIP OR IMMIGRATION STATUS
Complete one of the following to attest to your citizenship or immigration status.
United States Citizen
Noncitizen National of the United States
An individual born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of
noncitizen nationals born abroad.
A Lawful Permanent Resident
An individual who is not a U.S. citizen who resides in the United States under legally recognized and lawfully recorded permanent residence
as an immigrant.
An Alien Authorized to Work
An individual who is not a citizen or national of the United States, or a lawful permanent resident, but is authorized to work in the United
States.
Enter the date that your employment authorization expires__________________________________.
Aliens authorized to work must enter one of the following to complete this section:
1. Alien Registration Number (A-Number)/USCIS Number _____________________________________.
2. Form I-94 Admission Number__________________________________________________________.
3. Foreign Passport Number and the Country of Issuance______________________________________.

MRP FORM 126B
JULY 2020

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VOLUNTEER SERVICE AGREEMENT
SECTION II – Assignment Data to Be Completed by Federal Employee Supervisory Program Official
PROGRAM NAME

LOCATION

SUPERVISORY PROGRAM OFFICIAL’S NAME (Last and First)

SUPERVISORY PROGRAM OFFICIAL’S TITLE

PHONE NUMBER

EMAIL ADDRESS
LENGTH OF VOLUNTEER ASSIGNMENT

BEGINNING DATE

END DATE

HOURS/WEEK

DESCRIPTION OF SERVICE
Please define the role and services requested of the volunteer. Provide details describing duties, tasks and responsibilities, location of project/duties,
licensure, and/or certification if required, level of physical activity required, training if required, tools, equipment, and PPE needed and provided, supplies,
materials, etc. Include information regarding equipment and/or property that will be provided by the volunteer, if applicable. Attach additional sheets as
necessary. Please ensure that all attachments contain the name of the volunteer. Classified position descriptions will not be accepted.

Check all that apply, verify and initial, as required before submitting the agreement to the Volunteer Service Program Coordinator:
Uniform (if required); Initials of supervisor____________
Valid Driver’s License Verified (if required); Initials of supervisor____________
Valid Licensure/Certification Verified (if required); Initials of supervisor____________
Employment certificates or work permits as required by state or local authorities for volunteers under the
age of 18 Verified (if applicable); Initials of supervisor____________

Incidental Expenses Approved:

Yes

No

Type of Reimbursement:

Note: Volunteers receive no salary from USDA, but each volunteer’s incidental expenses for such items as transportation, lodging, and subsistence may
be covered. The executed agreement is the authorizing instrument for all incidental volunteer expenses that the Agency agrees to pay or reimburse.
Volunteers may be able to deduct certain unreimbursed expenses incurred in connection with their volunteer service from their reported income on Federal
income tax returns. Information on this subject is available from Internal Revenue Service taxpayer assistance offices.
CERTIFICATION TO BE COMPLETED BY FEDERAL EMPLOYEE SUPERVISORY PROGRAM OFFICIAL
I certify the volunteer service is in accordance with appropriate Federal, State, and local regulations, regarding employment of minors.
I agree to supervise the volunteer and provide materials, equipment, and facilities that are available and needed to perform the volunteer service described
above. A record of attendance will be prepared for the volunteer.
I certify that the volunteer services to be performed as outlined in this Volunteer Service Agreement, will not displace any employee.
SIGNATURE OF FEDERAL EMPLOYEE SUPERVISORY PROGRAM OFFICIAL

MRP FORM 126B
AUG 2020

DATE

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VOLUNTEER SERVICE AGREEMENT
SECTION III – VOLUNTEER AGREEMENT
I understand that:


I will not receive pay for services rendered.



I am permitted access to the work site only during my approved duty hours.



I am not considered a Federal employee for any purpose other than for purposes of the Federal Tort Claims provisions published
in 28 U.S.C. 2671 through 2680, and U.S.C. Chapter 81, relative to compensation for injuries sustained during the performance
of work assignments.



I am not eligible for health insurance, life insurance, retirement, or any other benefits.



If the Federal Government later employs me, my volunteer service will not be credited for civil service retirement purposes.
However, the experience I gain may be credited to meet qualification requirements for employment.



My volunteer assignment may require a reference check, background investigation, and/or criminal history inquiry in order to
perform my assignment.



I am to conduct myself with honesty and integrity in the performance of my assignment and follow the rules of conduct of MRP,
the Department of Agriculture, and the Federal Government.



I am to safeguard Government business, which is not for public information.



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 the agency for a determination of rights. Prior approval must be obtained prior to
publishing the results of any work, study, or research.



My supervisor must give permission before I operate any government equipment or handle any property that said equipment or
property may be used for approved, official purposes only, and that I may be held responsible for any unreasonable damage.



I serve under the supervision of a Federal official and I, or the Department of Agriculture, Marketing and Regulatory Programs
may terminate my services and this agreement at any time.

I agree to the conditions of my service as described above, to assist in authorized activities and to follow all applicable safety guidelines.
SIGNATURE OF VOLUNTEER

DATE

SECTION IV - PARENTAL OR LEGAL GUARDIAN CONSENT FOR VOLUNTEER UNDER 18 YEARS OF AGE
NAME OF PARENT OR LEGAL GUARDIAN (Print Last and First)
ADDRESS (Include City, State, and ZIP Code)

HOME PHONE NUMBER

MOBILE NUMBER

EMAIL ADDRESS
I affirm that I am the parent/guardian of the above named volunteer. I understand the services rendered by the volunteer are to be uncompensated
except for purposes of tort claims and injury compensation. I understand that the volunteer is not considered a Federal employee and that the
volunteer service is not creditable for any Federal employee benefit. I have read the description of the service that the volunteer will perform. I give
my permission for
__________________________________________________________ to participate in the specified volunteer activity.
(Print/Type Name of Volunteer

SIGNATURE OF PARENT OR LEGAL GUARDIAN

DATE

SECTION V - EMERGENCY CONTACT INFORMATION
NAME OF PARENT OR LEGAL GUARDIAN (Print Last and First)
ADDRESS (Include City, State, and ZIP Code)

HOME PHONE NUMBER

MOBILE NUMBER

EMAIL ADDRESS
MRP FORM 126B
AUG 2020

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VOLUNTEER SERVICE AGREEMENT
SECTION VI – VOLUNTEER SERVICE PROGRAM COORDINATOR
NAME (Print Last and First)
OFFICE LOCATION (Include City, State, and ZIP)

PHONE NUMBER
EMAIL ADDRESS

I agree to accept the volunteer service described in Section II in accordance with Departmental Regulation 4230-1.
SIGNATURE OF MRP VOLUNTEER SERVICE PROGRAM COORDINATOR

Distribution:

1 copy to volunteer, 1 copy to program contact

Original to:

MRP Volunteer Service Program Coordinator
USDA, MRPBS, HRD, HR Policy
4700 River Road, Unit 21
Riverdale, Maryland 20737

MRP FORM 126B
AUG 2020

DATE

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