1 Transfer Application Form

NATIONAL SERVICE TRUST

Request to Transfer a Segal Education Award Amount (#1)

Use this form if you wish to transfer all or part of your unused education award to your child, foster or step child, or step/grandchild. To transfer an education award, you must (1) have earned the award in an AmeriCorps State or National or Silver Scholar Program; (2) have been aged 55 or older on the date you began the approved term of service; and (3) have begun that term of service on or after October 1, 2009. You may revoke any unused balance of the transferred award prior to its expiration. You can transfer an award only once, except for specific reasons identified in the Code of Federal Regulations, or if the transfer was declined in full. The recipient of the award is bound by CNCS legislations and policies regarding the use of a Segal Education Award. Select the help button for additional information on award transfer criteria and constraints.

Part A: Award Information

[NSP ID] [Member’s name] select term of service [Available award balance]

Enter amount to be transferred from your account: _________________

Have you transferred any portion of this award in the past and revoked it in full? If yes, you must request a waiver to re-transfer. A waiver will be granted if the first recipient was unable to use the award for “good cause”, as determined by CNCS. To request a waiver check here . Please state your reason for revoking the original transfer ____________________________­­­­­­­­­­­­­­­­­­­­­___________________________________________________________________

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Part B: Recipient Information

Transfer recipient: _________________________ □ child □ foster or step child □ step/grandchild

Recipient’s SSN: ___________ Recipient’s date of birth (mmddyyyy): ________________

Recipient’s street address: _________________________ Telephone number______ ___________

City, state, and zip code: ________________________________________

Email address: _____________________  Check if the recipient does not have an e-mail address

I understand that the designated individual must use the education award I am transferring within 10 years of the date I completed the term of service upon which this award is based, and that CNCS will not grant an extension solely based on the award recipient not having reached an age to enroll in an institution of higher education or incur qualified student loans. I certify that all of the information I have provided above is true and correct to the best of my knowledge. I agree, by submitting this form, to provide documentation, if asked, to verify the accuracy of the information I have provided in this form. 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., exclusion from participation in federal programs, and forfeiture of benefits I may receive as a result of participation in this program, or other actions authorized by the Civil Fraud Remedies Act, 31 USC 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, as amended. This form is used by AmeriCorps members to request a transfer of all or a part of their Segal Education Award 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 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 a required Social Security Number or any other information may result in the application being 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-