Exit Certification

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 30 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 required to obtain or maintain benefits (Individuals with Disabilities Education Act (IDEA) and its corresponding regulations 34 CFR Part 304). 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 Pre-Scholarship Agreement to this address.

Service Obligation Exit Certification

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

Grant Awarded in Fiscal Year 2006 and Any Year Thereafter

Service Obligation Exit Certification

Between

_____________________________

Name of Scholar

And

______________________________

Name of Grantee

Upon completion or exit from grant-supported training, the grantee will require each scholar to use the OMB-approved Exit Certification in which the scholar agrees to the terms and conditions set forth in the regulations published on June 5, 2006 implementing section 662(h) of IDEA (see 34 CFR part 304), including the requirement that the Secretary track the service obligations of scholarship recipients. The regulations and Frequently Asked Questions (FAQs) are available at http://www.serviceobligations.ed.gov/ProgramRegs2006.cfm, and http://www.serviceobligations.ed.gov/2006faq.cfm.

According to section 304.23(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 U.S. Department of Education’s address for purposes of this Pre-Scholarship Agreement is:

OSEP PDP Data Collection Center

Grants Awarded in FY2006 and Any Year Thereafter
US Department of Education
Office of Special Education Programs
1600 Research Blvd, RA 1297
Rockville, MD 20850

Service Obligation Information and Exit Certification

Below you must enter the service obligation details for the scholar/obligee. This information is critical to tracking service obligation fulfillment. Note that after the completion of at least one academic year of training, a scholar/obligee may begin to fulfill his or her service obligation 2006 Regulations: §304.30(f)(2). An academic year is defined by the program regulations as "(1) A full-time course of study- (i) Taken for a period totaling at least nine months; or (ii) Taken for the equivalent of at least two semesters, two trimesters, or three quarters; or (2) For a part-time scholar, the accumulation of periods of part-time courses of study that is equivalent to an ‘academic year’ under paragraph (a) (1) of this definition." See Sec. B (1)- (2); 2006 Regulations: §304.3(a)(1)-(2).

Scholars/obligees who exit a training program prior to completion and have not finished at least one academic year of training will be referred for repayment to the Debt and Payment Management Group (DPMG) of the U.S. Department of Education. Scholars/Obligees will not receive credit for any employment positions held prior to the date of completion of one academic year. However, if a scholar completes a training program that is less than one academic year in duration, she/he may repay through service. See 2006 Regulations: §304.30.(j)(4)(iii).

All fields are required to submit the record.

1. Program Duration:

Select the most appropriate option below.

○ This program is less than one academic year in duration.

○ This program is more than one academic year in duration, but the scholar/obligee has not yet completed one academic year of training.

○ This program is more than one academic year in duration and the scholar/obligee completed one academic year of training on __________ (mm/dd/yyyy).

2. Accumulated academic years of funding under this grant (to date, if enrolled):__________

Enter durations less than one academic year as decimals. For example, 0.5 is half of one academic year of funding.

3. Total service obligation in months under this grant (to date, if enrolled):__________

This amount is calculated by multiplying accumulated academic years of funding by 24 months. Two years of service obligation are required for every academic year of scholarship support.

4. Total funding amount under this grant (to date, if enrolled):__________

Enter the amount of funding in dollars and cents.

Exit Certification

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

Grant Awarded in Fiscal Year 2006 and Any Year Thereafter

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

Grant Award Number: ____________________________________

Institution of Higher Education: ____________________________

Grantee Representative: ___________________________________

Project Title: _____________________________________________

Service Obligation Information

What is the number of academic years of assistance the scholar received from the Special Education -- Personnel Development to Improve Services and Results for Children with Disabilities?
What is the total amount of scholarship funding received from the Special Education -- Personnel Development to Improve Services and Results for Children with Disabilities program?
Did the scholar complete the academic program?
What was the date of program completion?
If the scholar did not complete the program, did the scholar complete at least one academic year of the program?
If the scholar failed to complete the academic program, or at least one academic year of the program, did you inform the scholar that he or she is ineligible to complete his or her service obligation through eligible employment and must repay the total amount of funding received?
If the scholar is eligible for service obligation through eligible employment, what is the number of years of eligible employment needed to satisfy the service obligation?
If the service obligation can be completed through eligible employment, what is the total number of years and months the scholar has to complete his or her service obligation (i.e., number of academic years funded times two (2) plus the five year grace period)?

To be completed by the Grantee Representative and 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 Information in this Exit Certification is correct.

____________________________________ ______________

Grantee Representative Signature Date

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

________________________ ______________________ ______________

Scholar Name Scholar Signature Date

(Please print)

Note: The completed Exit Certification must be certified within 30 days of completion or exit from the program by both the grantee and the scholar in the Service Obligation database at http://serviceobligation.ed.gov.

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