2 Award Transfer Acceptance Form

NATIONAL SERVICE TRUST

Accept/ Decline Award Transfer Form (#3)

Use this form to accept or decline a transferred Education Award. The person named below wishes to transfer all or part of an Education Award to you. In order to accept, you must be the child, grandchild, or foster child of the person making the transfer and you must be a citizen, national, or lawful permanent resident alien of the United States. You may use this award to pay for current educational expenses at a qualified institution of higher education, or to repay qualified student loans. You have 10 years from the date the transferred award was earned to use this award. Select the Help button for additional information on award transfer criteria and constraints.

Part A: Award Information

[NSP ID] [Member’s name] [award transfer amount] [Date award earned]

Part B: Recipient Information

[Name of Recipient] [SSN] [Date of birth] [Relationship to Transferring Individual]

[Address] Telephone number] [Email address]

If the information displayed above is not correct, please enter corrections in this box.

Indicate your citizenship status: □ US Citizen or National □ Lawful, Permanent Resident Alien

(Nationals of the US include persons born in America Samoa, including Swains Island. Generally, you are a Lawful Permanent Resident Alien of the US if you are a US permanent resident with (i) a Permanent Resident Card, INS Form I-551; (ii) an Alien Registration Receipt Card, INS Form I-551, (iii) a passport indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence; or (iv) an I-94 indicating that the INS has approved it as temporary evidence of lawful admission for permanent residence. NOTE: A student visa does not confer eligibility to enroll in an AmeriCorps program.

□ I accept in full the award transfer described in Part A and the conditions for its use.

□ I accept $_______, part of the award transfer described in Part A, and use conditions.

□ I decline the award transfer described in Part A.

I agree, by submitting this form, to provide documentation, if asked, to verify the accuracy of the information I have provided in this form. I certify that all of the information I have provided above is true and correct to the best of my knowledge. I understand that a knowing and 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 the 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 authorized by the provisions of the National and Community Service Act of 1990, as amended. This form is used by individuals to indicate their acceptance or declination of a Segal Education Award amount and to verify the recipient’s eligibility to receive the award transfer. Information may also be provided to federal, state, and local agencies for law enforcement purposes. Information will not otherwise be disclosed without written permission. The Internal Revenue Service has determined that the education award is taxable income in the year it is used. Failure to disclose the Social Security Number or any other information may result in the award transfer 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 the content of the form to the National Service Trust. 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-