Form 1 Ed Award Commitment Matching Form

Segal AmeriCorps Education Award

Matching ProgramCommitment Form

This form enrolls an institution of higher education in the Segal AmeriCorps EducationAward Matching Program. For more information, please visit www.nationalservice.gov/edawardmatch or email EdAwardMatch@cns.gov.

Section I: Institution Profile Information

Name of Higher Education Institution:__________________________________________________

If your institution’s match or benefit applies toa specific department or school, please listbelow. Otherwise, please note “All”:

___________________________________________________________________________________

Institution’s Website: __________________________________________________________________

City, State:__________________________________________________________________________

Primary Contact:

Name: ______________________________ Title: __________________________________________

Phone: ________________ Fax: _________________E-mail: _____________________________

Mailing Address: _____________________________________________________________________

Authorized Representativesigningthis form (if different from primary contact above):

Name: ______________________________ Title: __________________________________________

Phone: ________________ Fax: _________________E-mail: _____________________________

Institution Profile:

Institution Type (please check one):

# Public

Private

Types of programs your benefit applies to (check all that apply):

2-Year Degree(Associate)	4-Year Degree (Bachelor)
Graduate Degree	Other

Your institution is eligible to award Federal Student Aid Funds based on (check all that apply):

Title IV (check eligibility here)

VA Qualified (check eligibility here)

Is your institution a (check all that apply):

Faith-Based Institution	Historically Black College/University
Tribal College	Hispanic-Serving Institution

Hasyour Institution been listed on the President’s Higher Education Community Service Honor Roll?

Yes

No

Section II: Commitment Level

The four levels of participation in the Segal AmeriCorps Education Award Matching Program are described below. Please check the appropriate participation level and provide a more detailed description in the space provided below. Benefits may include the following expenses:

Waiver of application fee

Books and supplies

Room and board

Tuition and fees payable to the institution

Personal costs, transportation

Platinum

My institution will provide an individual benefit valued between76% and 100% of tuition expenses to at least one AmeriCorps alumnus each year.

Gold

My institution will provide an individual benefit valued between 51% and 75%of tuition expenses to at least one AmeriCorps alumnus each year.

Silver

My institution will provide an individual benefit valued between 26% and 50% of tuition expenses to at least one AmeriCorps alumnus each year.

Bronze

My institution will provide an individual benefit valued from a minimum of $1,000 to 25% of tuition expensesto at least one AmeriCorps alumnus each year.*

*Please note: Educational institutions must provide a minimum benefit of $1,000 per year to at least one AmeriCorps alumnus to participate in this program. For example, a $1,000 match to one student per year meets program requirements, while a $250 match to four students per year does not meet requirements.

The average yearly value of all benefitsmy institution awards to AmeriCorps alumni through this program totals:

(If your institution is a new participant, please indicate the total yearly value of the benefits you are committing to provide to AmeriCorps alumni.)

$1,000 - $5,000 $25,001 - $50,000 $100,001 - $150,000

$5,001 - $10,000 $50,001 - $75,000 $150,001 - $200,000

$10,001 - $25,000 $75,001 - $100,000 $200,001+

Please check here if the yearly value of your benefits to AmeriCorps alumni is unknown

Please check this box if your school will waive the application fee for all AmeriCorps alumni.

Provide a detailed description of what your institution offers through the Segal AmeriCorps Education Award Matching Program. CNCS will post this information on our website for potential students to access. Please include the amount of the dollar match along withany additional benefits that your institution offers.If you need additional space, please attach this information in a separate page:

Section III: Commitment Timeframe

Your institution’s participation in this program is valid for five (5) years from the date of signature on this agreement*.

*If the institution needs to terminate this agreement for any reason at any time, the institution must notify CNCS within 10 days of this decisionby emailing EdAwardMatch@cns.gov to allow CNCS to delete the website listing; otherwise, students will continue to contact the institution.

CNCS reserves the right to delete the website listing for any institution not in compliance with the Segal AmeriCorps Education Award Matching Program requirements.

_____________________________________________ ______________________________

Signature Date

Please return this form to:EdAwardMatch@cns.gov

OMB Control No. 3045-0143 Expiration Date: 08/31/2015