Form FEMA Form 119-25-3 FEMA Form 119-25-3 Studen Stipend Agreement

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

O.M.B. No. 1660-0100
Expires August 31, 2013

STUDENT STIPEND AGREEMENT
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 it displays a valid
OMB control number. 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, and 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 mandatory. Failure to provide the requested information may result in a delay in processing the reimbursement claim.
INFORMATION REGARDING THE USE OF YOUR SOCIAL SECURITY NUMBER UNDER PL 93-579, SECTION 7(b) consistent with PL 104-134: E.O. 9397 authorizes the collection of
the SSN. The SSN is required if you are seeking reimbursement under the Student Stipend Program. All payments made by the Federal Government require the SSN of the requestor.
Failure to provide your SSN will result in your stipend request being denied.
ACCOUNT TO WHICH REIMBURSEMENT WILL BE DEPOSITED:

NAME (Last, First, Middle)

Financial Institution Name:

SOCIAL SECURITY NUMBER

Routing #:

BUSINESS PHONE (Include area code)

Account Title:

MAILING ADDRESS

Account #:
Checking

Savings

No Stipend Requested
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.
DATE

SIGNATURE OF STUDENT
DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY
FA-MO ONLY

ACCOUNTING INFORMATION:
Total amount obligated:

APPROVAL

RECOMMENDED
Signature

FEMA Form 119-25-3, AUG 2010

NOT RECOMMENDED

APPROVED
Date
PREVIOUSLY FEMA Form 75-3

Signature

NOT APPROVED
Date