### For Official Use Only

**For Official Use Only** 

# National Service Trust Exit Form

This form wi ll end the term of a serving me mber 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. 

## PA **RT 1 Member: Please Complete and Sign**  **1 .**  **Name** Last First MI **2 .**  **Social Security Number**  **3 .**  **Ma iling A** **ddress** (W here the education award should be sent , if mailed ) Number and Street City State Zip Code **Email A ddress**  Home Phone Business Phone Ext **4. For VIST** **A Volunteers only: I would like to**  Extend m y service for less than a year Reenroll for another year Complete m y service as scheduled Terminate m y service early **5. If receiving a Segal Education A**  **ward, how do you plan to use it? (check all that apply)** Repay qualified loans Pa y 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 analy ses only. The information you provide will not be used in any way to determine or affect any federal benefit. CNCS provides me mb ers the option of checking a box indicating that they do not prefer not to respond. Wesincerely 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 phy

sical 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 sy stem, 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 Ph ys ical 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 im possible 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: Wh at is your highest level of education?

Less than high school High school diploma/GED Technical school/apprenticeship/vocational Som e 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**  **Choos e On**  **e** 

### If school is not listed, provide name here Type of degree, diploma, or certificate **Choos e One**  

### If you have an A**ssociate’s degree: Choose the school**  **from which you received your most recent A ssociate’s degree**  **Choos e On**  **e** 

### I f school is not listed, provide name here Type of degree, diploma, or certificate **Choos e On**  

### If you have a Bachelor’s degree: **Choose the school from which you received your most recent Bachelor’s degree**  **Choos e On**  **e** 

### If school is not listed, provide name here Type of degree, diploma, or certificate **Choos e One**  

### If you have a graduate degree: **Choose the school from which you received your most recent graduate degree Choos**  **e On e**  

### If school is not listed, provide name here Type of degree, diploma, or certificate **Choos e 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)**

Am erican Indian or Alaska Native Native Hawaiian or Other Pacific Islander Black or African American Wh ite 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: A**  **ll Honorably Discharged Veterans Qualify for Nomination for the Presidents Volunteer Service Aw**  **ard.** 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 Membe r 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 A** **ct 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 Em ail Telephone Number No, I do not give the Corporation for National and Community Service permission to release m y 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 yo u 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 a nd 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

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**For Official Use Only Certification of Service:**  **I certify** that the time I reported to m y 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. **Me mber's Signature:**  **Date: Privacy**  **Statemen** t
-- In compliance with the Privacy Act of 1974, the following informa tion is provided: The collection of this information is authorized by the provisions of the National and Community Se rvice Act of 1990, as amended

. The primary purpose of the information is to successfully enroll a member in a term of service and the educa tion award program. The evaluative information will help CNCS improve its programming and services to members. Information may b e 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 Nu mber may

b e released to the Social Sec urity 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 Se rvice 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 u se as a taxpayer identification number. Failu re 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 educatio n award. OMB No.: 3045
- 0015

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**For Official Use Only** Ex it information should be electronically submitted to CNCS within 30 days of completion of service. 

## PA **RT 2 Certify**  **ing Official: Please Complete and Sign** This section must be signed by an authorized certifying official. The program must designate certifying officials electronic ally to the Corporation for National and Community Service. **1. Name of Program or A** **meriCorps*NCCC Campus** **2. Operating Site I.D. Num**  **ber 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 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 A** 

**ward Status: Indicate whether or not the Member is eligible for an education award.**  **Please be sure to follow CNCS’s regula** **tions 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 t he 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 T h at the h ours of service p erformed indicated on this form for this service member are true and accurate. I understand that a knowing and willful false stateme nt 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
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. **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 nee ded to complete the form is 3 minutes for the Member section and 4 minutes fo r 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, N W, W ashington , DC 20525. CNCS informs the potential pers ons who are to respond to this collection of information that such persons are not required to respond to the collection of i nformation unless it displays a currently valid OMB control number on this page of the form (see 5CFR 1320.5(b)(2)(1)).