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

Segal AmeriCorps Education Award

Matching Program Commitment Form

This form enrolls 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

Name of 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 Website: __________________________________________________________________

City, State: __________________________________________________________________________

Primary Contact:

Name: ______________________________ Title: __________________________________________

Phone: ________________ Fax: _________________ E-mail: _____________________________

Mailing Address: _____________________________________________________________________

Authorized 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 institution is eligible to award Federal Student Aid Funds based on (check all that apply):

Title IV (check eligibility here) VA Qualified (check eligibility here)

Is your institution 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 No 
OMB 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 provided

below. Benefits may include the following expenses:

 Waiver 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 

AmeriCorps alumnus each year.

Gold

My institution will provide an individual benefit valued between 51% and 75% of tuition expenses to at least one 

AmeriCorps alumnus each year.

Silver

My institution will provide an individual benefit valued between 26% and 50% of tuition expenses to at least one 

AmeriCorps 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 your school will waive the application fee for all AmeriCorps alumni.

Provide a detailed description of what your institution offers through the Segal AmeriCorps

Education Award Matching Program. CNCS will post this information on our website for potential 

students to access. Please include the amount of the dollar match along with any additional benefits that 

your institution offers. If you need additional space, please attach this information in a separate page:
OMB 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 institution 

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 compliance with the Segal 

AmeriCorps Education Award Matching Program requirements.

_____________________________________________ ______________________________

Signature Date

Please return this form to: EdAwardMatch@cns.gov