National Service Trust Exit Form

This form will end the term of an AmeriCorps member in the National Service Trust and report on the eligibility 

of the member for a Segal Education Award. It will also provide AmeriCorps with evaluation exit data. This 

form may be filled out on paper or electronically.

PART 1 // Member: Please Complete and Sign

1. Name __________________________________________________ __________________________________________________ ______________________

Last First MI

2. Social Security Number _____________ — __________ — _____________

3. Mailing Address (Where the Segal Education Award should be sent, if mailed)

Number and Street _______________________________________________________________________________________________________________

City _____________________________________________________________________ State ____________________ Zip Code ____________________

Email Address ____________________________________________________________________________________________________________________

Home Phone _______________________________________ Business Phone _______________________________________ Ext __________________

4. For VISTA Volunteers only: I would like to

 Complete my service as scheduled

 Extend my service for less than a year

 Reenroll for another year

 Terminate my service early

AmeriCorps gathers information about education and disability status to ensure opportunities to serve are provided for people of 

all conditions. This information will be held confidentially, and will solely be used for data analysis to assist us in ensuring we serve all 

Americans equally. The information you provide will not be used in any way to determine or affect any federal benefit. Under the 

Rehabilitation Act (Act) information on your disability status can only be used in connection with non-discrimination and affirmative 

action obligations. The information will be kept confidential in accordance with the Act’s provisions and the information will be used 

only in accordance with the Act. 

5. Disability Status

The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment

policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of

medication and aids (except eyeglasses) or the help of another person.

Do you have one of the following? (Check all that apply to you)

 Deaf or serious difficulty hearing

 Blind or serious difficulty seeing even when wearing glasses

 Missing an arm, leg, hand, or foot

 Paralysis, partial or complete (any cause)

 Significant disfigurement (for example, severe disfigurements caused by burns, wounds, accidents, or congenital disorders)

 Significant mobility impairment (for example, use of a wheelchair, scooter, walker, or use of a leg brace to walk)

 Significant psychiatric disorder (for example, bipolar disorder, schizophrenia, PTSD, or major depression)

 Intellectual disability (formerly described as mental retardation)

 Developmental disability (for example, cerebral palsy or autism spectrum disorder)

 Traumatic brain injury

 Dwarfism

 Epilepsy or other seizure disorder

 Other disability or serious health condition (for example, diabetes, cancer, cardiovascular disease, anxiety disorder,

or HIV infection; a learning disability, a speech impairment, or a hearing impairment)

If you did not select one of the options above, please indicate why:

 I have a disability or serious health condition but do not wish to specify my condition

 I do not wish to answer questions regarding disability/serious health conditions.

 None of the conditions listed above apply to me.

Updated 09/2021

Page 1 of 4 Expires 04/30/2025
If you selected “Other disability or serious health condition”, please select any of the conditions listed below that apply to you. 

(Please check all that apply)

 Alcoholism

 Cancer

 Cardiovascular or heart disease

 Crohn’s disease, irritable bowel syndrome, or other gastrointestinal impairment

 Depression, anxiety disorder, or other psychological disorder

 Diabetes or other metabolic disease

 History of drug addiction (but not currently using illegal drugs)

 HIV infection/AIDS or other immune disorder

 Kidney dysfunction, for example, requiring dialysis

 Learning disabilities or ADHD

 Liver disease (for example, hepatitis or cirrhosis)

 Lupus, fibromyalgia, rheumatoid arthritis, or other autoimmune disorder

 Morbid obesity

 Nervous system disorder (for example, migraine headaches, Parkinson’s disease, or multiple sclerosis)

 Non-paralytic orthopedic impairments (for example, chronic pain, stiffness, weakness in bones or joints, or 

some loss of ability to use parts of the body)

 Orthopedic impairments or osteo-arthritis

 Pulmonary or respiratory impairment (for example, asthma, chronic bronchitis, or TB)

 Sickle cell anemia, hemophilia, or other blood disease

 Speech impairment

 Spinal abnormalities (for example, spina bifida or scoliosis)

 Thyroid dysfunction or other endocrine disorder

 Other. Please identify the disability or health condition: _________________________________________________________________________

6. Do you receive Social Security disability benefits, such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI)?

 Yes  No  Prefer not to respond

7. School Status

Has your highest level of education changed since you enrolled?

 Yes  No

If yes, please answer the following questions:

What is the highest level of education you have completed? 

 Less than high school  High school diploma/GED  Technical school/apprenticeship/vocational 

 Some college  Associates degree (AA)  College graduate  Graduate degree (e.g. MA, PhD, MD, JD)

If you have some college, list the most recent school you attended:

___________________________________________________________________________________________________________________________________

If you have an Associate’s degree, list the school from which you received your most recent Associate’s degree:

___________________________________________________________________________________________________________________________________

If you have a Bachelor’s degree, list the school from which you received your most recent Bachelor’s degree:

___________________________________________________________________________________________________________________________________

If you have a graduate degree, list the school from which you received your most recent graduate degree:

___________________________________________________________________________________________________________________________________

8. Privacy Act Information Release

 Yes, I give AmeriCorps permission to release the following information about me to an AmeriCorps Alumni Association 

(check all that apply):  Name  Address  Email  Telephone Number

 No, I do not give the AmeriCorps permission to release my information to an AmeriCorps Alumni Association.

9. Post Service Opportunities

AmeriCorps would like to provide you with information and resources to help you stay engaged in service and connect with 

educational, professional, and alumni opportunities. (Please check all that apply)

 I am interested in connecting with other AmeriCorps alumni.

 I am interested in learning more about educational opportunities and how to use my Segal Education Award.

 I am interested in professional development trainings, resume-writing resources, and career opportunities.

 I am not interested in this information and resources.

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Certification of Service

I certify that the time I reported to my program as program service hours is true and correct and did not include any service activities 

prohibited by law, regulation, or grant provisions. I agree, by signing this form, to provide, if asked, documentation to verify the 

accuracy of the information I have provided in this form.

I understand that a knowing and willful false statement on this form can be punished by one or more of the following: a fine or 

imprisonment (or both) under Section 1001 of Title 18, USC; exclusion from participation in Federal programs; 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.

Member’s Signature ____________________________________________________________________________ Date ______________________________

Privacy Act Statement: AmeriCorps is required by the Privacy Act of 1974 (5 U.S.C. 552a) to tell you what personal information we collect 

via this website (e.g. name, contact information, demographics, education and employment history, criminal history, medical 

information) and how it will be used. 

Authorities – My AmeriCorps requests your personal information pursuant to 42 U.S.C. Chapter 129 - National and Community Service, 

42 U.S.C. Chapter 66 - Domestic Volunteer Services, and Executive Order 9397, as amended. 

Purposes – It is requested to (1) manage your application, service, and post-service benefits and (2) evaluate how to enhance AmeriCorps. 

Routine Uses – Routine uses of this information may include disclosure to complete your background check, to process your payments, 

to manage and oversee your service, and other reasons consistent with why it was collected. 

Effects of Nondisclosure – This request is voluntary, but not providing the information may limit your ability to become a Member, 

continue being a Member, or receive Member benefits. 

Additional Information – The applicable system of records notice is CNCS-04-CPO-MMF-Member Management Files (MMF).

The Internal Revenue Service has determined that the Segal Education Award is taxable in the year it is used. Your Social Security 

Number (SSN) is solicited under the authority of the Internal revenue Code (26 U.S.C. 6011(b) and 6109) for use as a taxpayer 

identification number. Failure to disclose your actual SSN or any other information may result in a denial of your receiving a Segal 

Education Award or it may delay the processing of your education award. 

Public reporting burden—Estimated time to complete this form, including time for reviewing instructions, gathering, and providing the 

information needed to complete the form is three minutes for the Member section and four minutes for the Certifying Official section. 

Send comments regarding this burden or the content of this form to: AmeriCorps, 250 E Street SW, Washington, DC 20525. AmeriCorps 

informs the potential persons who are to respond to this collection of information that such persons are not required to respond to the 

collection of information unless it displays a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1)).

Page 3 of 4 OMB Approval No.: 3045-0006
PART 2 // Certifying Official: Please Complete and Sign

This section must be signed by an authorized certifying official. The program must designate certifying officials electronically to AmeriCorps. 

1. Name of Program or AmeriCorps*NCCC Campus _________________________________________________________________________________

2. Operating Site I.D. Number _______________________________________________________________________________________________________

3. Hours of Service Performed ______________________________ (not applicable for VISTA) Hours 

4. Date of Completion of Term of Service _______________________ ___________ ___________ Month Day Year

5. Type of Enrollment (check only one)

 Full-time (1700 hours per year, or 365 days per year for VISTA)

 VISTA Summer Associate (10-12 weeks)

 Half-time (900 hours in no more than 2 years)

 Half-time (900 hours in no more than 1 year)

 Reduced half-time (675 hours)

 Quarter-time (450 hours)

 Minimum time/Summer (300 hours)

 AmeriCorps Affiliate (100 hours)

6. Segal Education Award Status

Indicate whether or not the Member is eligible for a Segal Education Award. Please be sure to follow the AmeriCorps regulations 

in making this selection. If the Member is going to serve another term under the National Service Trust, a new National Service 

Enrollment Form must be completed. 

 Eligible for entire Segal Education Award (member successfully completed service) 

 Eligible for partial Segal Education Award (member did not fully complete service for compelling personal reasons) 

 Not eligible for Segal Education Award (member did not fully complete service requirements) 

 Not eligible for Segal Education Award (member chose alternative benefit) 

 Not eligible for Segal Education Award (member dismissed for misconduct)

 Not eligible for Segal Education Award

 Other (Specify): ________________________________________________________________________________________________________________

7. Did the member perform satisfactorily (complete all assignments, tasks, and projects)?

Note: responding “No” may restrict future membership opportunities for this individual 

 Yes  No

8. Certification of Service 

I certify that to the best of my knowledge and belief, the time the above-listed member reported as AmeriCorps, Silver Scholar, or 

Serve America Fellow program service hours did not include any service activities prohibited by law, regulation, or grant provision;

That the member performed satisfactorily (completed all assignments, tasks, and projects); and that the hours of service performed 

indicated on this form for this service member are true and accurate. 

I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under 

Section 1001of Title 18, U.S.C. or other actions authorized by the Civil Fraud Remedies Act, 31 USC 3801-3812.

Signature of Certifying Official __________________________________________________________________ Date ______________________________

Name of Certifying Official (Please Print): ____________________________________________________________________________________________

For Official Use Only

For Official Use Only Page 4 of 4

Exit information should be electronically submitted to AmeriCorps within 30 days of completion of service.