Encl. (1) to COMDTINST 1780.2A
Coast Guard Morale, Well-being, and Recreation (MWR)
Payment In Kind Internship Program
Agreement
I desire to provide in kind my services to ___________________ as an MWR Payment In Kind
Student Intern on
(name of CG unit)
_________________________________________________________________________.
(describe anticipated hours/day(s) of week at unit)
I expressly agree that my services are being provided as a Payment In Kind Intern and that I am
not an employee of the United States Government or any instrumentality thereof except for
certain purposes relating to compensation for injuries occurring during the performance of
approved payment in kind services and liability for tort claims as specified in 10 U.S.C.
1588(d)(2). I expressly agree that I am neither entitled to nor expect any present or future salary,
wages, or other benefit for these Payment In Kind services. I agree to be bound by the laws and
regulations applicable to payment in kind service providers, and agree to participate in any
training required by the organization to which I am working, to enable me to perform the
Payment In Kind services that I am offering.
I have been provided a copy of the Affiliation Agreement between ____________________
(name of school)
and the Coast Guard MWR Program, and agree to adhere to all applicable provisions.
_________________________________________
___________________________
(typed or printed name and signature of volunteer)
(date)
Contact Information: ________________________________________________________
(address and phone numbers)
__________________________________________
___________________________
(typed or printed name and signature of accepting official: local command)
(date)
For agency use only: Provide general description of the Payment In Kind services to be
provided by the intern student:
___________________________________________________________________________
___________________________________________________________________________
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 9397, 10 U.S.C. 1588
PRINCIPAL PURPOSE: To document participation in the Coast Guard Morale, Well-being, and
Recreation (MWR) Internship Program.
ROUTINE USES: None.
DISCLOSURE IS VOLUNTARY. However, failure to provide the information requested could
result in our inability to place you in the Internship Program.
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