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

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
OMB Control No. 1660-0100
Expires: 11/30/2016

STUDENT STIPEND AGREEMENT

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 2 minutes. The burden estimate includes the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of
information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for
reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 1800 South Bell
Street, Arlington, VA 20598-3005, Paperwork Reduction Project (1660-0100) NOTE: Do not send your completed form to this 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 SECIRUTY NUMBER
BUSINESS PHONE (Include area code)

Routing #:
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.

SIGNATURE OF STUDENT

DATE
DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY
ACCOUNTING INFORMATION:

FA-MO-ONLY

Total amount obligated:
APPROVAL

RECOMMENDED
Signature

FEMA FORM 119-25-3 (05/16)

NOT RECOMMENDED
Date

APPROVED
Signature

NOT APPROVED
Date
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