Pre-Scholarship Agreement & Exit Cert 2005

OMB Control Number: 1820-0686

Expiration: XX/XX/XXXX

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 67 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is mandatory per the Individuals with Disabilities Education Act of 2004 (IDEA) and its corresponding regulations 34 CFR Part 304 printed in the Federal Register Volume 70 No. 57 March 25, 2005 and Vol. 71 No. 107 June 5, 2006.Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email [email protected] and reference the OMB Control Number 1820-0686. Note: Please do not return the completed Service Obligation Agreement to this address.

Service Obligation Agreement

For a Scholarship Received from a Personnel Preparation to Improve Services and Results for Children with Disabilities

Grant Awarded in Fiscal Year 2005

Service Obligation Agreement

Between

_____________________________

Name of Scholar

And

______________________________

Name of Grantee

For grants awarded in FY 2005, the "Additional Requirements" section of the Personnel Preparation to Improve Services and Results for Children with Disabilities--Combined Priority for Personnel Preparation and Preparation of Leadership Personnel notice, published in the Federal Register on March 25, 2005, including the requirement that the Secretary track the service obligations of scholarship recipients. The requirements are attached. The requirements and Frequently Asked Questions are also available at http://www.serviceobligations.ed.gov/ProgramRegs2005.cfm, and http://www.serviceobligations.ed.gov/2005%20faq.pdf.

According to section304.23(a), the Secretary may grant a deferral or an exception to the work or repayment requirements upon request, if a scholar or an obligee can provide sufficient evidence to substantiate eligibility.

The current address of the Department of Education for purposes of this agreement is:

OSEP Service Obligations Contact

Grants Awarded in FY2005, FY2006 and Any Year Thereafter
US Department of Education
Office of Special Education Programs
400 Maryland Avenue, SW
Washington, DC 20202-2600

To Be Completed by the Grantee

Grant Award Number: H325

Grantee:

Project Title:

Course of Study or Program:

Project Director:

Date of Scholarship Assistance and Service Obligation Meeting:

To be completed by the scholar

Scholar Name:

Date of Birth:

Social Security Number:

Street Address:

City, State, Zip Code:

E-mail Address:

Alternate Contact Information

Name:

Relationship:

Street Address:

City, State, Zip Code:

Telephone Number:

E-mail Address:

To Be Completed by Scholar

I have:

(a) read and understand the attached service obligation regulations and FAQs, including the service obligation of two years of service for every academic year of support or to repay the scholarship;

(b) read Attachment A (US Citizenship and Residency Requirements) of this Agreement;

(c) provided the information requested of me in this Agreement and Attachment A to the grantee representative;

(d) completed the Certification of Eligibility for Federal Assistance form (ED 80-0016); and (e) I agree to the requirements outlined in this document and the “Additional Requirements" section of the Personnel Preparation to Improve Services and Results for Children with Disabilities--Combined Priority for Personnel Preparation and Preparation of Leadership Personnel notice, published in the Federal Register on March 25, 2005 as a condition for accepting IDEA scholarship funds.

______________________________ _______________________________ ____________

Scholar Name Scholar Signature Date

(Please print)

To be Completed by the Grantee Representative

I have met with the scholar and discussed the service obligation requirements and provided him/her with a copy of the regulations and the frequently asked questions.

____________________________ ___________________­­­­­­­­________ ___________

Grantee Representative Name Grantee Representative Signature Date

(Please print)

Exit Certification

For a Scholarship Received from a Personnel Preparation to Improve Services and Results for Children with Disabilities

Grant Awarded in Fiscal Year 2005

To be completed by the Grantee Representative/Project Director when a scholar exits or completes the program:

Grant Award Number: ____________________________________

Grantee: ____________________________

Grantee Representative: ___________________________________

Project Title: _____________________________________________

Service Obligation Information

Number of academic years IDEA scholarship assistance was received
Date of program completion
Total amount of IDEA scholarship assistance received	$
Number of years of eligible work needed to satisfy the service obligation
Time period during which the scholar must satisfy the service obligation

To be completed by the Grantee Representative or Scholar upon exiting or completing the program:

Scholar Contact Information

Scholar Name
Scholar Social Security Number
Scholar Address after Completing or Exiting the Program
Scholar E-mail Addresses after Completing or Exiting the Program
Scholar Telephone Number after Completing or Exiting the Program
Phone number, address and e-mail address for the scholar’s family member or friend who can forward mail, if necessary.
Scholar’s employer, if known (Agency name, address, and telephone number)

I certify that the Service Obligation in this Exit Certification is correct.

____________________________________ _____________________

Grantee Representative Signature Date

I understand and agree that the Service Obligation and Contact Information in this Exit Certification are correct.

________________________ ______________________ ______________

Scholar Name Scholar Signature Date

(Please print)

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