3135-0112 National Heritage Fellowships Acceptance Form

General Information and Instructions for

NATIONAL ENDOWMENT FOR THE ARTS

National Heritage Fellowships
Legal Name:
(last)

(first)

(middle initial)

(title)

How would you like your name(s) to
appear on the award certificate?

Permanent Address (number
and street):
(city, state and zip):

Phone:

Social Security #:

Birth Date:

Place of Birth:

U.S. Citizenship:

Yes

No

If Permanent Resident, Visa #

1. Purpose and Scope: NEA National Heritage Fellowships are awarded by the National
Endowment for the Arts:

In recognition and support of your significant impact on and your
continuing contributions to the folk and traditional arts.
2. Acceptance: Indicate your acceptance of this fellowship by completing this form and
forwarding it to us via email or fax. (Please make a copy for your own records.)
I accept the National Endowment for the Arts’ Individual Fellowship Grant in the amount of $25,000. By signing
below, I certify that the information contained herein is true and correct to the best of my knowledge, and that I will
comply with the Federal requirements specified below.
The Drug-Free Workplace Act of 1988 was enacted on November 18, 1988, as part of Federal omnibus drug
legislation. This law requires applicants for Federal grants to certify that they will not engage in the unlawful
manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any grant activity.
(For the purposes of this Act, alcohol is not considered a controlled substance.) Your signature on this form fulfills
the certification required of individuals.
A government-wide regulation for implementing the law was published in the Federal Register at 54 FR 4946, on
January 31, 1989. It became effective on March 18, 1989. Therefore, as of that date, the Arts Endowment is not
able to award any new grants to organizations or individuals unless the applicant has provided the required
certification.
Are you delinquent on the repayment of any Federal debt?

X
Signature

No

Yes If yes, please attach explanation

Date