Commonwealth of Massachusetts Human Resources Division



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Commonwealth of Massachusetts

Human Resources Division

SERV Volunteer Program www.mass.gov/serv

Revised Verification Form September 2011

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





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