Form 119-25-4 Student Stipend Agreement (Amendment)

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0100
Expires May 31, 2010

STUDENT STIPEND AGREEMENT (AMENDMENT)
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 valid 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), December 31, 1974, for individuals applying for student stipend
reimbursement from the Federal Emergency Management Agency.
Authorities: Public Law 93-498, 15 U.S.C. 2206, 5 U.S.C. 301, 50 U.S.C. APP. 2253, E.O. 12127 and E.O. 12148, Public Law 81-920, section 201(e), Public Law
93-288, section 201(e), and Public Law 104-134.
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 (NETC), the Mount Weather Emergency Assistance
Center (MWEAC), 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.
STUDENT'S NAME (Last, first, middle)

ACCOUNT TO WHICH REIMBURSEMENT WILL BE DEPOSITED:
Financial Insititution Name:

BUSINESS ADDRESS (Include area code)

Routing #:
MAILING ADDRESS

Account Title:
Account #:
Checking

Savings

A student stipend agreement was approved for the above named individual in the amount of $

. Actual verified travel cost have exceeded the original

stipend payment. This amendment provides a stipend supplement for total actual travel cost. All other provisions of the original stipend contract remain the same.
STUDENT CERTIFICATION
I certify that the round- trip costs from my home to NETC, MEWAC, or other off campus locations exceeded my original travel stipend by

$

, and I request

reimbursement of that amount. Attached is documentary proof of the actual expense. I understand that I must file for reimbursement within 60 days of start of course or my claim will be
denied.
STUDENT'S SIGNATURE

DATE
DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY

ACCOUNTING INFORMATION:

Initial Stipend:

$

Obligated This Agreement:

$

Total Obligation:

$
APPROVAL

RECOMMENDED

Signature
FEMA Form 119-25-4, JUL 07

NOT RECOMMENDED

APPROVED

Date

DISAPPROVED

Signature

PREVIOUS EDITION OBSOLETE

Date