**National Service Trust Exit Form**

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

of the member for an education award. It will also provide the Corporation for National and Community Service (CNCS) with evaluation exit data. This form may be filled out on paper or electronicall y.

**PART 1** Member: Please Complete and Sign
1. Name
Last First
MI 2. Social Security

Number 3. Mailing Address (Where the 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 Reenroll for another ye ar Extend my

service for less than a y ear Terminate m y service earlyCNCS 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 analy sis to assist us in ensuring we serve all Ame ricans equall y. The information you provide will not be used in any way to determine or affect an y federal benefit. Under the Rehabilitation Act (Act) information on y our disabilit y status can onl y be used in connection with non

- discrimination and affirm ative 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. Your responses are required in order to successfully verify y our service. 5. Di sability

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 phy sical or mental conditions. Consider y our answers without the use of medication and aids (except ey eglasses) or the help of another person. Do y ou have one of the following? Check all that apply to y ou: Deaf or serious difficulty hearing Blind or serious difficulty seeing even when wearing glasses Missi ng an arm, leg, hand, or foot Paraly sis, partial or complete (any cause) Significant disfigurement, for example, severe disfigurements caused b y burns, wounds, accidents, or congenital disorders Significant mobility

impairment, for example, use of a wheelc hair, scooter, walker, or use of a leg brace to walk Significant ps ychiatric 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 wh y: I have a disability

or serious health condition but do not wish to specify my condition I do not wish to answer ques tions regarding disability /serious health conditions. None of the conditions listed above appl y to me. If you selected “Other disability or serious health condition”, please select any of the conditions listed below that apply to y ou. Please check all that appl y.Alcoholism Cancer Cardiovascular or heart disease Crohn’s disease, irritable bowel sy ndrome, or other gastrointestinal impairment Depression, anxiety

disorder, or other ps yc hological disorder Diabetes or other metabolic disease History of drug ad diction (but not currentl y using illegal drugs) HI V infection/AIDS or other immune disorder Kidney dy sfunction, for example, requiring dialy sis Learning disabilities or ADHD Liver disease, for example, hepatitis or cirrhosis Lupus, fibrom yal gi a, rheumatoid arthritis, or other autoimmune disorder Morbid obesity Nervous s ys tem disorder, for example, migraine headaches, Parkinson’s disease, or multiple sclerosis Non

- paraly

tic 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, c hronic bronchitis, or TB Sickle cell anemia, hemophilia, or other blood disease Speech impairment Spinal abnormalities, for example, spina bifida or scoliosis Thy roid d ys function or other endocrine disorder Other. Please identify

the disability

or health c ondition:

6. Do y ou receive Social Security disabilit y benefits, such as Supplemental Security In come (SSI) or Social Security Disability

I nsurance (SSDI)? Yes No Prefer not to respond

7. School Status Has your highest level of education ch anged since you enrolled? Yes No If yes, please answer the following questions: What is your highest level of education? 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:

Choose the most recent school y ou attended If school is not listed, provide name here Ty pe of degree, diploma, or certificate
If you have an Associate’s degree: Choose the school from which y ou received y our most recent Associate’s degree If school is not listed, provide name here Ty pe of degree, diploma, or certificate
If you have a Bachelor’s degree: Choose the school from which y ou re ceived y our most recent Bachelor’s degree If school is not listed, provide name here Ty pe of degree, diploma, or certificate
If you have a graduate degree: Choose the school from which y ou received y our most recent graduate degree If school is not listed, provide name here Ty pe of degree, diploma, or certificate

8. Privacy

Act Information Release Yes, I give the Corporation for National and Community Service permission to release the following information about me to an AmeriCorps Alumni Ass ociation (check all that appl y): Name Address Email Telephone Number
0 No, I do not give the Corporation for National and Community Service permission to release m y information to an AmeriCorps Alumni Association. 9. Post Service Opportunities: The Corporation for National and Community Service would like to provide y ou with information and resources to help y ou stay engaged in service and connect with educational, professional, and alumni opportunities. Please check all that apply

. I am inter ested in connecting with other AmeriCorps alumni. I am interested in learning more about educational opportunities and how to use my education award.I am interested in professional development trainings, resume

- writing resources, and career opportunities. 0 Corps I am not interested in this information and resources. 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 an y service activities prohibited by law, regula tion, or grant provisions. Iagree, by

signing this form, to provide, if asked, documentation to verify the accuracy

of the information Ihave 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 aut horized by the Civil Fraud Remedies Act, 31 USC 3801

- 3812. Member’ s Signature: Date: Privacy Statement

-- In compliance with the Privacy Act of 1974, the following information is provided: The evaluative information will help CNCS improve its programming and services to members. Information may be shared with other agencies, such as the Social Security Administration, through computer matching agreements for the purpose of verifying identity information pr ovided by y ou in this document. The Interna l Revenue Service has determined that the education award is taxable in the y ear 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 taxpay er identification number. Failure to disclose y our actual SSN or any other information may

result in a denial of your receiving an education award or it may delay the processing of your education award. All information provided will be treated confidentially and will not be disclosed except for an official need to know. 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 3 minutes for the Membe r section and 4 minutes for the Certifying Official section. Send comments regarding this burden or the content of this form to: Corporation for National and Community Service, National Service Trust, 1201 New York Avenue, NW, Washington, DC 20525. CNCS informs the potential persons who are to respond to this collection of information that such persons are not requi red to respond to the collection of information unless it display s a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1)).

OMB No.: 3045

- 0006Exit information should be electronicall y submitted to CNCS within 30 days of

completion of service.
**PART 2** Certifying Official: Please Complete and Sign This section must be signed by an authorized certifyingofficial. The program must designate certifying officials electronicall y to the Corporation for National and Communi ty Service.
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. Ty

pe of Enrollment (Mark onl y one.) Full

- time (1700 hours per y ear, or 365 day s per y ear for VI STA) VI STA Summer Associate (10

- 12 weeks) Half

- time (900 hours in no more than 2 y ears) Half

- time (900 hours in no more than 1 y ear) Reduced half

- time 675 hours Quarter time 450 hours Minimum time/Summer 300 hours

6. Education Award Status: Indicate whether or not the Member is eligible for an education award. Please be sure to follow CNCS’s 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 education award (member successfully completed service) Eligible for partial education award (member did not fully complete service for compelling personal reasons) Not eligible for education award (member did not fully complete service requirements) Not eligible for education award (member chose alternative benefit) Not eligible for education award (member dismissed for misconduct) Not eligible for education award. Other (Specify):7. Did the member perform satisfactoril y (complete all assignments, tasks, and

projects)? Note, responding “No” may restrict future membership opportunities for this individual Yes No
8. Certification of Serv ice 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 gran t provision; That the member performed satisfactoril y (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):