DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY
STUDENT STIPEND AGREEMENT
O.M.B. No. 1660-0100
Expires May 31, 2010
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 2 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering
and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a vaild OMB control number appears
in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management,
Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0100). NOTE: Do not send your
completed form to the above address.
Privacy Act Statement
GENERAL: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), Title 5 United States Code (U.S.C.), Section 552a, for individuals applying for student stipend
reimbursement from the Department of Homeland Security, FEMA.
AUTHORITIES: Federal Fire Prevention and Control Act of 1974, as amended, Title 15 U.S.C., Sections 2201 et.seq.; Robert T. Stafford Disaster Relief and Emergency Assistance Act, as
amended, Title 42 U.S.C., Sections 5121 et. seq.; Title 44 U.SC.,Section 3101; Executive Orders 12127, 12148, and 9397; Title VI of the Civil Rights Act of 1964; and Section 504 of the
Rehabilitation Act of 1973.
PURPOSES AND USES: The purpose of the information requested on this document and any supporting documents is to facilitate the review, approval, accounting, and reimbursement of funds
for the expense of student attendance at the National Emergency Training Center, the Mount Weather Emergency Operations Center, the Noble Training Facility, or selected off-campus locations.
EFFECTS OF NONDISCLOSURE: Submission of the information is voluntary; however, failure to provide the requested information may result in a delay in processing the reimbursement claim.
NAME (Last, First, Middle)
BUSINESS PHONE (Include area code)
MAILING ADDRESS
ACCOUNT TO WHICH REIMBURSEMENT WILL BE DEPOSITED:
Financial Institution Name:
Account Title:
Routing #:
Account #:
I understand that the stipend for which I am applying is a portion of the Federal Government's share of the expense of attending a course offered by the National Fire Academy (NFA) or the
Emergency Management Institute (EMI). I have read and understand the reimbursement limits as explained in my acceptance material.
If, due to my own fault, I fail to successfully complete the course in which I am enrolled, the Superintendent may deny reimbursement after consideration of relevant evidence. Appeal of the
Superintendent's decision may be made by filing a written request with the Director, NETC Management, Operations and Support Services, 16825 S. Seton Avenue, Emmitsburg, MD 21727,
within 10 working days of receipt of the Superintendent's initial decision. His decision is final.
I understand that, under the terms of this agreement, I will not receive any of the rights, benefits, and privileges of a Federal employee. It is further understood that my presence on Government
property will be in accordance with Federal laws that govern such property.
I understand that FEMA is limited by law to the portion of student expenses for attendance which they may reimburse and that I may be required to pay a portion of this expense.
I understand that this reimbursement will be electronically deposited into the account I designated above. I further understand that I should expect to receive reimbursement within 6-8 weeks of
start date of the course.
I understand that I must file for reimbursement at time of registration of resident courses, within 30 days of start of selected off-campus courses, or within 60 days of start of Regional Delivery
courses, or my claim WILL be denied.
I certify that the stipend expenses for which I am seeking reimbursement do not qualify for reimbursement under any other program, Federal or otherwise.
If I am claiming reimbursement for POV travel, I certify that I am the vehicle's driver, and no passengers are claiming reimbursement.
Odometer Start
Odometer End Vehicle License No.
SIGNATURE OF STUDENT DATE
Checking
Savings
DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY
FA-MO ONLY
ACCOUNTING INFORMATION:
Total amount obligated:
APPROVAL
Signature
Date
Signature
Date
RECOMMENDED
NOT RECOMMENDED
APPROVED
NOT APPROVED
FEMA Form 75-3, JUL 07 PREVIOUS EDITION OBSOLETE
Resume Templates 1210 Document(s)
