Form FEMA Form 119-25-4 FEMA Form 119-25-4 Studen Stipend Agreement (Amendment)

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

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

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)

BUSINESS PHONE (Include area code)

MAILING ADDRESS

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, MWEAC, 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, AUG 2010

NOT RECOMMENDED

APPROVED

Date

Signature

PREVIOUS EDITION OBSOLETE

DISAPPROVED

Date