# NATIONAL SERVICE TRUST

**Request to Transfer**  **a Segal Education**  **Award Amount (#1)**  **Use this form if you wish to transfer all or part of your unused education award to your**  **child, foster or**  **step child**  **, or**  **step/ grandchild**  **.** To transfer an education award, y ou mu st (1) have earned the award in a n AmeriCorps State or National or Silver Scholar Program ; (2) have been aged 55 or older on the date you began the approved term of service ; and (3) have begun that term of service on or after October 1, 2009. You may rev oke any unused balance of the transferred award prior to its expiration

. You can transfer an award only once , except for good cause , or if the transfer was declin ed in full

. The recipient of the award is bound by CNCS legislation and policies regarding t he use of a Segal Education Award

. Select the help button for additional information on award transfer criteria and constraints

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### Part A: Award Information [NSP ID] [ Member ’s name ] select term of service [A vailable a ward balance ] Enter amount to be transferred from your account: _________________ Have you transferred any portion of this award in the past and revoked it in full? If yes, you must **request a wa**  **iver** to re - transfer **.** A waiver will be granted if the first recipient was unable to use the award for “good cause”, as determined by CNC S. To request a waiver **check here**

. Please state your reason for revoking the original transfer

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### Part B: Recipient Information
Transfer r ecipient : _________________________ □ child □ foster or step child □ step/ grandchild Recipient’s SSN: ___________ Recipient’s d ate of birth (mmddyyyy) :

________________ Recipient’s s treet ad dress:
_________________________ Telephone number______ ___________ City, state, and zip code: ________________________________________ Email address: _____________________ Check if the recipient does not have an e - mail address
**I understand** that the designated individual must use the education award I am transferring within 10 years of the date I completed the term of service upon which this award is based, and that the Co rporation will not grant an extension solely based on the award recipient not having reached an age to enroll in an institution of higher education or incur qualified student loans. **I certify** that all of the information I

have provided above is true and c orrect to the best of my knowledge. **I agree** , by submitting this form, to provide documentation , if asked , to verify the accuracy of the i nformation I have provided in this form. **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 programs, 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. Submitting this 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 aut horize d by the provisions of the National and Community Service Act of 1990, as amended by the National & Community Service Act of 1993 and the Serve America Act of 2009 . This form is used by AmeriCorps members to request a transfer of all or a part of their Seg al Education Award to a qualified recipient and to verify certain legal requirements. Information may also be provided to federal, sta te, and local agencies for law enforcement pu rposes. Information will not oth erwise 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 i s used. Failure to disclose a required Social Security Number or any other info rmation may result in the application 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 burden or th e content of the form to the National Service T rust . Respondents are not required to fill out this form unless it displays a valid OMB control number on this page. (See 5 CFR 1320 5(b)(2)(b)). OMB Number 3045

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