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Attachment 11 - Member Exit Form (pdf)


AmeriCorps Illinois

AMERICORPS EXIT FORM
National & Community Service Logo

This form will end the term of an AmeriCorps member in the National Trust and report on the eligibility of the member for an education award. It will also provide the Corporation with evaluation exit data.This form will end the term of an AmeriCorps member in the National Trust and report on the eligibility of the member for an education award. It will also provide the Corporation with evaluation exit data.

Directions to Member

  1. Use blue or black ink.
  2. Print clearly
  3. Please complete and sign Part 1.
  4. Return the completed form to your Program Director. AmeriCorps*VISTA members should return the forms to the Corporation State Office.

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)
    • Number and Street
    • City
    • State
    • Zip Code
    • Email Address
    • Home Phone
    • Business Phone
    • Ext
  4. Post Service Opportunities:
    The Corporation for National and Community Service would like to encourage you to stay involved in service and help you connect with educational, professional, and alumni opportunities. If you are interested in staying connected with the following organizations, please let us know.
    • Yes, I give the Corporation for National and Community Service permission to release my name, address (including e-mail), and telephone number to the following types of organizations:
      • Educational institutions that are interested in recruiting former AmeriCorps members or that provide special programs for former members
      • Organizations offering professional development opportunities or staff positions to AmeriCorps members
      • AmeriCorps Alumni organizations
      • Organizations that sponsor service opportunities and want to recruit AmeriCorps members

I am particularly interested in the following issue areas (please mark all that apply):

  • Education
  • Public Safety
  • Housing
  • Environment
  • Health
  • Disaster Relief
  • Homeland Security
  • Faith and Community Based
  • No, please do not share my information with other organizations

Certification of Service:

I certify that the time I reported as AmeriCorps service hours did not include any service activities prohibited by law, regulation, or grant provision.

I certify that all of the information provided above is correct.

  • Member's Signature:
    • Date:

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.

Privacy Act 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, as amended by the National and Community Service Trust Act of 1993. The primary purpose of the information is to obtain from AmeriCorps program representatives their determination of whether a member successfully completed a term of service and is eligible to receive an education award. The evaluative information will help the Corporation improve its programming and services to members. For individuals who have indicated their desire to receive additional information on alumni organizations or special educational opportunities for alumni, members' names, addresses, and phone numbers will be shared with those organizations for that purpose. Information may also be provided to federal, state, and local agencies for law enforcement purposes. Information will not otherwise be disclosed outside the Corporation without written permission. 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 (28 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 Expires: 07/31/2010


For Official Use Only


Directions to Certifying Official
  1. Use blue or black ink.
  2. Print clearly
  3. Please complete and sign Part 2.
  4. If you are using WBRS or eSPAN (for VISTAs), please provide the form to whomever enters data into that database for your program.

Exit information should be electronically submitted to the Corporation 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 (Hours) (not applicable for VISTA)
  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 for VISTA)
    • Half-time (900 hours in up to 2 years)
    • 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 the Corporation'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. Other (Specify):
    • Did the member perform satisfactorily (complete all assignments, tasks, and projects)
      • Yes
      • No
  7. Certification of Service
    To the best of my knowledge and belief, the time the above-listed member reported as AmeriCorps service hours did not include any service activities prohibited by law, regulation, or grant provision.

I certify that the Hours of Service Performed indicated on this form for this AmeriCorps member are true and accurate.

Signature of Certifying Official:

  • Date:

Name of Certifying Official (Please Print):

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.

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. The Corporation 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)).

OMB No.: 3045-0015 Expires: 07/31/2010


For Official Use Only