Service Payback Agreement

OMB Control Number: 1810-0698

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 mandatory per Title VI of the Elementary and Secondary Education Act, 20 USC §7442, and its corresponding regulations at 34 CFR Part 263. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Angela Hernandez-Marshall, Education Program Specialist, Office of Indian Education, U.S. Department of Education, 400 Maryland Ave SW, Room 3W113, Washington, DC 20202 or email [email protected]. Note: Please do not return the completed Service Payback Agreement to this address.

Service Payback Agreement

For Support and Training Received from an Indian Education Professional Development Program Grant Awarded to Grantee in Fiscal Year 2009 and Any Year Thereafter

Service Payback Agreement

Between

_____________________________

Name of Participant

And

______________________________

Name of Grantee

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority for collecting the requested information about the participant is section 7122 of the Elementary and Secondary Education Act of 1965, as amended. We request the participant’s information pertinent to the Indian Education Professional Development Program (PDP) grant received whether provided by the participant, grantee, or other entity, including social security number and other personally identifiable information (PII), under this authority in order to accurately track the participant’s records and to differentiate the participant’s financial obligation from other participants who may have the same name. The participant’s participation in the PDP is voluntary, but you must provide the requested information, including the participant’s PII, in order for the participant to participate in the PDP. The information will be used to ensure that recipients of scholarships provided with funds section 7122 of the Elementary and Secondary Education Act of 1965, as amended, meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in the participant’s records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the computer matching requirements of the Privacy Act, under a computer matching agreement. 

The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may also send this information to law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act.

Prior to granting support and training to a participant, the grantee will require each participant to enter into a written agreement in which the participant agrees to the terms and conditions set forth in the regulations for the Indian Education Professional Development Program (see 34 CFR part 263), including the requirement that the Secretary of Education track the service payback of participants. The regulations are available at:

https://www.gpo.gov/fdsys/pkg/FR-2015-04-22/pdf/2015-09396.pdf

The current address of the U.S. Department of Education for purposes of this agreement is:

U.S. Department of Education

Office of Indian Education

Professional Development Program

400 Maryland Avenue, SW

Washington, DC 20202

To Be Completed by the Grantee

Grant Award Number:

Grantee:

Project Title:

Project Director:

Date of Service Payback Meeting:

Estimated total amount of training months:

Estimated total amount of funds/support:

To Be Completed by the Participant

Name:

Date of Birth:

Social Security Number:

Street Address:

City, State, Zip Code:

E-mail Address:

To Be Completed by the Participant

I have read and agree to the Service Payback Regulations, including statements (a) through (d) below:

(a) I have read and understand the payback obligation (“work payback”) equal to the total period of time for which training was received; the requirement that work payback be related to the training received and benefits Indian people; that if I do not meet the work payback requirement, I must repay the total amount of funds received and expended for my training (“cash payback”) or a prorated amount based on approved work-related service; that I will inform the U.S. Department of Education of my intention to complete either a work payback or cash payback within 30 days of completion of my training, per instructions by the U.S. Department of Education;

(b) I have provided the information requested of me in this Agreement to the grantee representative;

(c) I have completed the Certification of Eligibility for Federal Assistance form (ED 80-0016); and

(d) I agree to comply with the regulations for the Indian Education Professional Development Program (34 CFR part 263), including the requirement to provide the information necessary to the Secretary to track my service payback.

I certify that all of the information I have provided is true and correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I may be fined in an amount not less than $5,000 and not greater than $10,000, plus 3 times the amount of damages the Government sustains due to my false statement. - False Claims Act, 31 USC § 3729.

___________________________ _______________________________ ___________

Participant Name Participant Signature Date

(Please print)

To be Completed by Grantee Representative

I have met with the participant and discussed the service payback requirements and provided him/her with a copy of the regulations.

I certify that all of the information I have provided is true and correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I may be fined in an amount not less than $5,000 and not greater than $10,000, plus 3 times the amount of damages the Government sustains due to my false statement. - False Claims Act, 31 USC § 3729.

___________________________ _________________________ __________

Grantee Representative Name Grantee Representative Signature Date

(Please print)

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