3 Award Transfer Rescind Form

NATIONAL SERVICE TRUST

Rescind Acceptance of Award Transfer Form (#15)

Use this form if you wish to rescind your acceptance of a Transferred Education Award. You may take back your acceptance of any unused portion of an award transferred to you at any time before it expires and for any reason prior to its expiration. This decision is final. “Unused portion” means the available balance, not including any outstanding payment requests. Select the Help button for additional information on this use of your transferred award. A separate form is required for each rescission.

Part A: Transfer Award Information

[NSP ID] [Award donor’s name] [TA ID#] [award transfer amount]

Part B: Recipient Information

[NSP ID] [Name of Recipient] TA ID# [available balance of transfer award]

□ I rescind in full my acceptance of the award transfer described in Part A.

□ I rescind $__________, a part of the award transfer described in Part A

You may take back your acceptance at any time prior to using the transferred award. However, this decision is final.

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 certify that all of the information I have provided above is true and correct to the best of my knowledge. 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, U.S.C.., 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 U.S.C. 3801-3812.

Submitting the 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 individuals to indicate their acceptance or declination of a Segal Education Award amount and to verify the recipient’s eligibility to receive the award transfer. Information may also be provided to federal, state, and local agencies for law enforcement purposes. Information will not otherwise be disclosed outside the CorporationCNCS 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 the Social Security Number or any other information may result in the award transfer 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- 0136 Expiration 8/31/2017