For Official Use Only

For Official Use Only

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. 

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

 Extend my service for less than a year Reenroll for another year

 Complete my service as scheduled Terminate my service early

5. If receiving a Segal Education Award, how do you plan to use it? (check all that apply)

Repay qualified loans

Pay for future higher education costs

Other allowable activity

Not sure

Prefer not to respond

CNCS gathers information about sex, race, ethnicity, education, and disability status for demographic and data analyses 

only. The information you provide will not be used in any way to determine or affect any federal benefit. CNCS provides 

members the option of checking a box indicating that they do not prefer not to respond. We sincerely hope that you will 

answer these sensitive questions to assist us in analyzing our ability to serve all Americans equally.

6. Disability status.

A disability is a physical or mental impairment that substantially limits one or more major life activities (or bodily functions). 

Major life activities include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, 

sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, 

communicating, and working. The term “major life activity” also includes the “operation of a major bodily function, including 

but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, 

respiratory, circulatory, endocrine, and reproductive functions.

Are you a person with a disability? Yes No Prefer not to respond

If yes:

Please check any of the following conditions that may apply to you.

Learning Disability 

Visual Disability/Blind 

Hearing Disability/Deaf

Speech Disability 

Mobility Disability 

Physical Disability (without a mobility disability)
For Official Use Only

For Official Use Only

Psychological Disability

Neurological Disability

Person on the autism spectrum

Developmental Disability

Chronic Illness 

Disability that is impossible to fit in a category above.

7. School Status

Has your highest level of education changes 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 you attended

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose One

If you have an Associate’s degree:

Choose the school from which you received your most recent Associate’s degree

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose On

If you have a Bachelor’s degree:

Choose the school from which you received your most recent Bachelor’s degree

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose One

If you have a graduate degree:

Choose the school from which you received your most recent graduate degree

Choose One

If school is not listed, provide name here 

Type of degree, diploma, or certificate Choose One
For Official Use Only

For Official Use Only

8. What is your sex?

Female Male

9. Are you registered to vote?

Yes No

Not sure Not eligible Prefer not to respond

10. Which of the following categories best describes your racial origin? (check all that apply)

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Black or African American

White

Asian American

Other

Prefer not to respond

11. Which of the following categories best describes your ethnic origin?

Hispanic or Latina/o Not Hispanic or Latina/o Prefer not to respond

12. What is your Military, Veteran, or Family member Status? (check all that apply)

Note: All Honorably Discharged Veterans Qualify for Nomination for the Presidents Volunteer Service 

Award. 

I am a Veteran

I am an Active Duty Member of the U.S. Armed Forces 

I am a Member of the National Guard or Reserve Component

I am an immediate family member of a Veteran

I am an immediate family member of an Active Duty Member of the U.S. Armed Forces

I am an immediate family member of a National Guard Member or Reservist

I am not in the military, a veteran or a family member of someone in the US. Armed Forces

Prefer not to respond

13. 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

14. 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 Association (check all that apply):

 Name Address

 Email Telephone Number

No, I do not give the Corporation for National and Community Service permission to release my 

information to an AmeriCorps Alumni Association.

15. Post Service Opportunities: 

The Corporation for National and Community Service 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 education award.

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

I am interested in information about serving again through AmeriCorps or the Peace Corps
For Official Use Only

For Official Use Only

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 Statement -- 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. The primary purpose of the information is to successfully enroll a member in a term of service and the education 

award program. 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 and citizenship status information provided by you in this 

document. In furtherance of CNCS’s efforts to ensure that the programs are inclusive of persons with disabilities, your Social Security Number may be released to the Social 

Security Administration to measure aggregate statistical data on the number of AmeriCorps members receiving disability-based benefits. Information may also be provided to 

federal, state, and local agencies for law enforcement purposes. The Internal Revenue Service has determined that the 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 the 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. 

 OMB No.: 3045-0015
For Official Use Only

For Official Use Only

Exit information should be electronically 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 certifying official. The program must designate certifying officials electronically to the 

Corporation for National and Community 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. Type of Enrollment 

(Mark 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

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): 

Did the member perform satisfactorily (complete all assignments, tasks, and projects)? Note, responding “No” may restrict future membership 

opportunities for this individual Yes No

7. 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):

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 Member 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 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)).