1 2016 Voucher and Payment Request Form

For Official Use Only

NATIONAL SERVICE TRUST - MANUAL PAYMENT REQUEST FORM

for Segal Education Award Recipient: SSN:

Part A – The member has registered and submitted this payment request online in the AmeriCorps automated epayments system.

(1) Amount member has requested and authorized to be taken from his/her account. $ ________________

(2) This disbursement for current education expenses is for the period ___________________ (amount) (term)

(3) The member has authorized the release of any payment information to the National Service Trust. Certifications and signature of the member are stored electronically (4) date of request: _______________

Month Day Year

Part B – To be completed ONLY by the EDUCATIONAL INSTITUTION or LOAN HOLDER - Fill out the appropriate portion depending upon whether the voucher is to repay a qualified student loan or to pay for current educational expenses. Include the complete address where the payment should be sent. Send the completed voucher to the National Service Trust address below to receive payment. See “Guidelines & Uses” sent to students with this voucher. Do not reuse processed vouchers. Please register online at www.americorps.gov to complete payment requests electronically.

B.1 LOAN PAYMENT REQUEST SECTION: the loan holder must complete this section.

A qualified student loan for the purposes of the education award is: a loan made, insured, or guaranteed pursuant to Title IV of the Higher Education Act of 1965, other than a loan to a parent of a student pursuant to section 428B of such Act; any loan made pursuant to Title VII of VIII of the Public Health Service Act; or a loan determined by an institution of higher education to be necessary to cover a student’s cost of attendance at such an institution and made, insured, or guaranteed directly to the student by a state agency. * indicates a mandatory field.

1. *Loan Number: __________________________ 2. *Payoff amount (add 30 days interest): $ ____________________

3. *Federally Guaranteed Loan Name:_____________________________

4. If a state agency-made loan, name of agency: _________________________

The organization named in B.3 below is the holder of the loan (which is defined as the original lender or another person or organization to which the loan was subsequently sold, transferred, or assigned and which has a legally enforceable right to receive payment from the borrower).

B.2 CURRENT EDUCATIONAL EXPENSES SECTION: the Title IV school or the institution eligible to receive GI Bill educational benefits (for members eligible to use their award at these GI Bill institutions) must complete this section.

The member named in Part A is a student enrolled in the institution named in Part B, which has in effect a Title IV Program Participation Agreement with the U.S. Dept of Education or is one eligible to receive GI Bill education benefits, or both. Eligibility to participate in any of the Title IV programs has not been limited, suspended, or terminated. Further, the number of students using an award in the current academic year is not more than 15% of the total student population. “Current” means expenses incurred during or after the member’s term of service in AmeriCorps.

1. The Cost of Attendance $________

less any other student aid or comparable allowed amount for non-degree programs. This is the amount the student is eligible for. The total of all student aid, including the education award, cannot exceed the CoA or the comparable amount allowed for non-degree programs. Veterans benefits may not be included in CoA calculation for AmeriCorps payments. Please do NOT simply state the Education Award balance.

2. School enrollment period upon which this amount is based: enrollment start date___________ enrollment mid point date ____________ (both dates mandatory)

(1^st installment) (2^nd installment)

For amounts exceeding $10.00, payment is made in two equal installments; one at the beginning and one at the middle of the enrollment period unless that period is in the past or within 10 days of the scheduled payment date.

3. Title IV School Code (6 digits): _____________

4. If an education or job training program approved by the Secretary of Veterans Affairs: Check here 

The institution named below certifies that the amount requested will be used to pay all or part of the member’s expenses attributable to a course or program of education, apprenticeship, or job training offered by that institution, and that the course or program is currently approved by the Secretary of Veterans Affairs or the designated state approving agency for the state where the institution is located. Note that transferred award amounts may not be used to make payments for this purpose. Refunds of any education award amounts must be made to the National Service Trust. These programs are limited to veterans only. Please enter VA (School) Facility Number: _____________________

B.3 Name of School or Loan Holder (Payee): __________________________________________________________________

Address____________________________________________________________________________________________

City____________________________________________ State _________ Zip Code _____-____

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Federal Taxpayer ID Number (9 digits): _____________________________ Customer Service e-Mail: ____________________________________________________

I certify that all of the information I have provided above is true and correct. 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 or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812

________________________________________________________________________ ______________________________ ______________________________

Full signature of authorized representative of the educational institution or loan holder Phone Number (including area code) Fax Number

Printed or typed name of representative________________________________________ Dept. _________________________ Date __________________

MAIL VOUCHER TO: NATIONAL SERVICE TRUST/CNCS; 250 E STREET SW, WASHINGTON, D.C. 20525

Or fax to 202 606 3484

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 education award recipients to request a payment to schools or lenders, to verify eligibility for the payments, and by both parties 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 outside the Corporation 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 payment being delayed or 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 at the address listed above. 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 3045-0014

For Official Use Only