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B Control No. 3045- 0143 Expiration Date : 08/31/2015



## Segal **Am eriCorps Education A**  **wa rd**  **Matching Program Commitment Form**  This form enroll s an institution of higher education in the Segal AmeriCorps Education Award Matching Program. For more information, please visit www.nationalservice.gov/edawardmatch or email EdAwardMatch@cns.gov . 

## Section I: **Institution Profile Information**  **Nam e o**  **f Higher Education Institution**  **:**

_ ____________________________________ ______ ___ ____ If your institution’s match or benefit applies to a specific department or school, please list below . Otherwise, please note “All.” :

______________________________________________________________________________ _____ Institution’s W ebsite:

_____________________ ________________

_____________________________ City, State :

______________________________ ___ __________________________ ________

__ _____ **Primary Contact:**  Name : _____________________ _________ Title: ________________________

___________

___ ____ Phone: ________________ Fax: _________

________ E - mail: ______________________

___ ____ Ma iling Address:

______________________ ________________________________________ ___ ____ **Au thorized**  **Representative signing**  **this form (if different from primary contact above)**  **:** Name: _____________________ _________ Title: ___________________________________

___ ____ Phone: ________________ Fax: _________

________ E - mail: ______________________

_______ **Institution Profile:**  **Institution Type**  **(please check one**  **) :**  Public Private **Types of programs your benefit applies to**  **(check all that apply )**  **:** 2 -Year Degree (Associate) 4 -Year Degree (Bachelor) Graduate Degree Other **Your i nstitution is eligible to a** **w ard Federal Student A** **id Funds b ased on (check all that**  **apply):** Title IV (check eligibility here ) VA Qualified (check eligibility here ) **Is y our i**  **nstitution a**  **(check all that apply ):**  Faith - Based Institution Historically Black College/University Tribal College Hispanic - Serving Institution **Has your Institution**  **been listed on the**  President’s Higher Education Community Service Honor Roll ? Yes NoOM

B Control No. 3045- 0143 Expiration Date : 08/31/2015 

## Section II: Commitment Level The four levels of participation in the Segal AmeriCorps Education Award Matching Program are described below. Please check the appropriate participation level and provide a more detailed description in the space provide d below. **Benefits may**  **include the fo llowing expenses:** 
 Wa iver of application fee  Books and supplies  Room and board  Tuition and fees payable to the institution  Personal costs, transportation **Platinum** My institution will provide an individual benefit valued **between 76% and 100%**  of tuition expenses to at least one Am eriCorps alumnus each year. **Gold** My institution will provide an individual benefit valued **between 51%**  **and 75%**  of tuition expenses to at least one Am eriCorps alumnus each year. **Silver** My institution will provide an individual benefit valued **between 26%**  **and 50%**  of tuition expenses to at least one Am eriCorps alumnus each year. **Bronze** My institution will provide an individual benefit valued from a **minimum of $1,000 to 25%**  of tuition expenses to at least one AmeriCorps alumnus each year. * *Please note: Educational institutions must provide a minimum benefit of $1,000 per year to at least one AmeriCorps alumnus to participate in this program. For example, a $1,000 match to one student per year meets program requirements, while a $250 match to four students per year does not meet requirements. The average yearly value of all benefits my institution awards to AmeriCorps alumni through this program totals (If your institution is a new participant, please indicate the total yearly value of the benefits you are committing to provide to AmeriCorps alumni ) : $1,000 - $5,000 $25,001 - $50,000 $100,001 - $150,000 $5,001 - $10,000 $50,001 - $75,000 $150,001 - $200,000 $10,001 - $25,000 $75, 001 - $100,000 $200,001 + Please check here if the yearly value of your benefits to AmeriCorps alumni is unknown **Please check this box if y our school will waive the application fee for all A** **meriCorps alumni. P**  **rovide a detailed description of what your institution**  **offer s through**  **the Segal A** **meriCorps Ed**  **ucation Aw**  **ard Matching Program .**  CNCS will post this information on our website for potential students to access. Please i nclude the amount of the dollar match along with any additional benefits that your institutio n offers . If you need additional space, please attach this information in a separate page :OM

B Control No. 3045- 0143 Expiration Date : 08/31/2015 

## Section III: Commitment Timeframe Your institution’s participation in this program is valid for five (5) years from the date of signature on this agreement * . ***** **If the institution needs to terminate this agreement for any reason**  **at any time ,**  **the institut**

**ion must notify CNCS**  **within 10 days of this decision**  **by emailing EdAwardMatch@cns.gov**  **to allow**  **CNCS to delete the website listing;**  **otherwise, students will continue to contact the institution.**  CNCS reserves the right to delete the website listing for any institution not in comp liance with the Segal AmeriCorps Ed ucation Award Matching Program requirements.

____________________________________________ _ _______________________ _______ Signature Date Please return this form to: **EdA wa**  **rdMatch@cns.gov**