SERV Verification Form of Volunteer Services
You should submit the original of this signed form to your state agency human resources or payroll office. 

Part 1- To be completed by the state employee SERV volunteer
Your Name: 	     
Your Employee ID      
Your State Agency:      
Your State Agency Address:        
Your State Work Phone #:        
Type of volunteer organization in Massachusetts (Check one)
		Public School	including Charter Schools 
		Other educational volunteering	
		Youth Mentoring
		Environment	 	
		Health    
 		Human Services	
 		Public Safety  

Volunteer Program Name/Address:      
Date of Volunteer Service:       
Time you arrived at volunteer site:      
Time you departed from volunteer site:      
Total hours volunteered excluding lunch break:  	VOL hours to put on timesheet        
Describe your volunteer duties performed today:                                                                            

_____________________________			     
Volunteer Signature					Date

Part 2 - To be Completed by the Volunteer Organization

Please ensure that all fields above are completed by the volunteer before signing.
I certify that the volunteer has not been awarded and will not receive any compensation or reimbursement by the organization or entity for the volunteer work performed. This is not a political organization. In addition the volunteer activities do not promote religion as the Massachusetts State Constitution (Amendment XVIII, § 2) prohibits public funds from supporting religious institutions.  I have visited www.mass.gov/serv and read the SERV program guidelines (http://www.mass.gov/Eoaf/docs/hrd/policies/leave/serv_guidelines.doc) to learn more about the SERV program.
_____________________________				     
Volunteer Organization Signature				Date