3135-0112 National Heritage Fellows Acceptance Form and Instructio

OMB# 3135-0112, Exp: TBD
General Information and Instructions for
NATIONAL ENDOWMENT FOR THE ARTS
National Heritage Fellowships

Legal Name:

(last)

(first)

(middle initial)

(Ms./Mr./Dr.)

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

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

U.S. Citizenship:
Birth Date:

Yes

No

If Permanent Resident, Visa #
Place of Birth:

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

Privacy Act
The following notice is furnished in accordance with the Privacy Act of 1974, 5 U.S.C.
552a:
This information is solicited under the authority of the National Foundation on the Arts
and the Humanities Act, 20 U.S.C. 951 et seq. and is used for the purpose of grant
awards. Personal data including home address and home telephone number will not be
released and is exempt from disclosure under FOIA exemption (b)(6). Failure to provide
the requested information could result in rejection of your application.
Paperwork Reduction Act Statement
The public reporting burden for this collection of information is estimated at an average of one
hour per response. This includes the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. We welcome any suggestions that you might have on improving the
guidelines and making them as easy to use as possible. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to: [email protected], attention: Reporting Burden. Note: Applicants are not
required to respond to the collection of information unless it displays a currently valid U.S. Office
of Management and Budget (OMB) control number.