SMART Scholarship SMART Scholarship-for-Service Program Service Agreement

SMART Scholarship-for-Service Program

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OMB No.
OMB Approval expires

SCIENCE, MATHEMATICS, AND RESEARCH FOR TRANSFORMATION (SMART)
SCHOLARSHIP-FOR-SERVICE PROGRAM SERVICE AGREEMENT
PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 2192a, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 5 U.S.C. 3304, Competitive service
examinations; 20 U.S.C. 17, National Defense Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPLE PURPOSE(S): To record a service agreement for an individual receiving a SMART scholarship.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To academic institutions for the
purpose of providing progress reports for applicants and participants; to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C.
1681a(f)) or the Federal Claims Collection Act of 1966 (31 U.S.C. 3701(a)(3)). The purpose of this disclosure is to aid in the collection of outstanding debts owed to
the Federal government, typically to provide an incentive for debtors to repay delinquent Federal government debts by making these debts part of their credit
records;
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure When Requesting Information
Routine Use, Disclosure of Requested Information Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the
National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use.
The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices
may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
The applicable Privacy Act System of Records Notice is DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information Management
System, found at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570592/dusda-14.aspx
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in SMART participant not being compliant with SMART policy and subject
to possible dismissal.
1. RECIPIENT
a. FULL NAME (Last, First, Middle Initial)

b. SOCIAL SECURITY NUMBER

c. MAILING ADDRESS
(1) STREET AND APARTMENT/SUITE NUMBER

(2) CITY

(3) STATE

(4) ZIP CODE

2. REFUND OBLIGATION ACKNOWLEDGEMENT AND TERMINATION OF ASSISTANCE
I understand that if I withdraw from the SMART Scholarship Program (SSP) at any time after my award is funded, if I fail to fulfill my post-graduation
service commitment, if I am dismissed from the program for failure to comply with any program policy or procedure, or if I am dismissed from the
program for misconduct, this Agreement will be terminated. I understand that I will be subject to debt repayment procedures and may be required to
promptly refund all federal funds expended under this Agreement, including all stipends, tuition, approved related educational fees, health insurance
allowances, book allowances, internship support payments, and any other financial assistance provided by the United States under this Agreement, plus
interest on that amount from the date of the award under Section 3717 of Title 31, penalties and all other amounts associated with collection. I
understand that this obligation to reimburse the United States is for all purposes a debt owed to the United States.
3. AWARD INFORMATION
a. COHORT YEAR
b. AWARD TYPE (X one) Recruitment Retention
c. ACADEMIC INSTITUTION
d. DEGREE (X one) BS

BS/MS

4. APPROVED FACILITY
a. SPONSORING SERVICE
5. DURATION OF AWARD
a. BEGINNING (MMDDYYYY)

MS

PhD

e. FIELD OF STUDY

b. SPONSORING FACILITY

c. LOCATION (city/state)

b. ENDING (MMDDYYYY)(degree completion
date)

c. TOTAL AWARD DURATION (Years)

6. AWARD AMOUNT
a. ANNUAL STIPEND RATE
c. ANNUAL HEALTH INSURANCE ALLOWANCE RATE

b. WEEKLY INTERNSHIPSUPPORT
PAYMENT RATE (if eligible)
d. ANNUAL MISCELLANEOUS
ALLOWANCE RATE

7. SERVICE OBLIGATION (Initial in space provided)
____ Based on the currently calculated duration of my award, I understand that I am required to complete ______ years (equal to Section 5c) of postgraduation service at my approved sponsoring facility (SF). I understand that if I do not fulfill my entire service obligation under this program, this
Agreement will be terminated; I will be dismissed from the SSP and will be responsible for the prompt refund of all federal funds in accordance with
Section 2 of this agreement. I further understand that my SF may have additional service requirements to that of the SSP. The SSP service
commitment is in addition to any other period for which I am obligated to serve in the civil service of the United States.
8. COMPLIANCE OBLIGATION AND FULFILLMENT OF SERVICE AGREEMENT (Initial in space provided)
____ I understand that I am required to fulfill this SMART Service Agreement, and comply with all program policies and procedures, including policies
set forth in this Agreement and the SMART Scholarship-for-Service Participant Handbook. I agree to obtain prior approval from the SSP and my SF as
required before making any academic or administrative change to this award or to my funded degree program (i.e. change of degree completion date,
change of degree pursued, change of academic institution, etc.). This Agreement constitutes the full agreement between the parties, and any
representation, statements, or communications not specifically incorporated herein, shall not be binding or of any force or effect.
9. DISCLAIMER (Initial in space provided)
____ I understand that the SSP and this Agreement is subject to the availability of funds. The terms of this SMART Service Agreement are severable.
In the event that any part, term or provision of this agreement is deemed invalid or otherwise unenforceable by a court of law with proper jurisdiction, the
remainder shall not be affected and shall remain in full force and effect.

SMART Service Agreement, revised 2015

SMART Scholarship-for-Service Program

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10. ACKNOWLEDGEMENT OF STATUS (Multi-year recruitment participants only. Initial in space provided)
____ I expressly agree that I am subject to all the terms and conditions, policies and procedures of the SMART Scholarship Program including an
internship. I expressly agree that pursuant to 10 U.S.C. 2360, during my participation in a SMART Scholarship internship at a Sponsoring Facility (SF), I
will not be an employee of the United States Government or any instrumentality thereof, except for certain purposes relating to compensation for injuries
occurring during the performance of approved internship activities and liability for tort claims, the Privacy Act, and criminal conflicts of interest. I
expressly agree that, I am neither entitled to nor expect any present or future salary, wages, or other benefits for the internship. I agree to be bound by
the laws and regulations applicable to interns and agree to participate in any training required by the SF, DoD laboratory, installation, or unit for me to
participate in the SMART internship. I agree to follow all rules and procedures of the SF, DoD laboratory, installation, or unit where my internship is
located.
11. CERTIFICATION BY RECIPIENT
This SMART Service Agreement is an important condition of your award. Please read it carefully before signing.
I certify that I have read and understand the conditions, terms, and requirements of this SMART Service Agreement and that I will comply with them.
I certify that I will be 18 years of age or older as of August 1, 20__.
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED (MMDDYYYY)
Legal Guardian Signature required if SSPP is under 18 years of age at time of award.
d. GUARDIAN NAME (Last, First, Middle Initial)
e. SIGNATURE

f. DATE SIGNED (MMDDYYYY)

12. Component Administrative Officer SMART DEFENSE EDUCATION PROGRAM
a. NAME (Last, First, Middle Initial)
b. SIGNATURE

c. DATE SIGNED (MMDDYYYY)

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing the burden, to the Department of Defense, Washington headquarters Services, Executive Services Directorate, Directives Division, 4800
Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 OMB Control Number: 0704-0466. Respondents should be aware that notwithstanding any other provisions of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

SMART Service Agreement, revised 2015