# NATIONAL SERVICE TRUST

**Rescind Acceptance of**  **Award Transfer**  **F orm**  **(# 15**  **) Use this form**  **if you wish to**  **rescind your acceptance of a T**  **ransferred Education A**  **ward .**  You may take back your acceptance of any unused portion of an award transferred to you at any ti me before it expires and for any reason prior to its expiration
. This decision is final. “U nused portion ” means t he available balance, not including any outstanding payment requests. Select the Help button for additional information on this use of your transfer red 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 re**  **scind in full**  my acceptance of t he 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 th e 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 abo ve is true and correct to the best of my knowledge. **I understand** that a knowing a nd 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 progra ms, 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.

S ubmitting 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 by the National & Community Service Trust Act of 1993 and the Serve America Act of 2009 . This form is used by individuals to indicate their acceptance or declination of a Segal Education Award amount and to verify the recipient’s e ligibility to receive the award transfer. Information may also be provided to federal, sta te, 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 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 bur den 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 13 20 5(b)(2)(b)). OM B Number 3045

-