5770-07 Fellowship Activation Notice

OMB Control No. 2030-0020
Approval expires MM/DD/YYYY

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0020). Responses to this collection of
information are required to obtain an assistance agreement (40 CFR Part 30, 40 CFR Part 31, and 40 CFR Part 33 for awards made prior to December 26, 2014, and 2 CFR 200, 2
CFR 1500, and 40 CFR Part 33 for awards made after December 26, 2014). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 0.5 hours per
response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to
the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number
in any correspondence. Do not send the completed form to this address.

UNITED STATES

EPA FELLOWSHIP

ENVIRONMENTAL PROTECTION AGENCY

ACTIVATION NOTICE

WASHINGTON, D.C. 20460

(Please type or print clearly)

FELLOWSHIP NO.
DATE FELLOW WILL ENTER ON DUTY

NOTICE:

EPA provides any payments to the sponsoring institution by check and provides any payments to the fellow either
electronically or by check as determined appropriate by EPA.
NAME OF FELLOW
NAME OF SPONSORING INSTITUTION
MAILING ADDRESS FOR PAYMENTS TO FELLOW (include ZIP code)

MAILING ADDRESS FOR PAYMENTS TO INSTITUTION (include
ZIP code)

FOR EPA USE ONLY
STIPEND

BOOK ALLOWANCE
TUITION & FEES
TOTAL AWARD

AWARD PERIOD

MONTHLY
$
TOTAL
$
$

FROM

$

LEVEL

THROUGH

SPECIAL INSTRUCTIONS

Agency
$

Special

PREPARED BY

DATE

REMARKS

SPECIALIST FOR PROJECT

AREA CODE

TELEPHONE NO.

SIGNATURE OF FELLOW

AREA CODE

TELEPHONE NO.

DATE

APPROVING SIGNATURES
AREA CODE

TELEPHONE NO.

DATE

SPONSOR OR DEPARTMENT HEAD (Please indicate)

EPA Form 5770-7 (6-73) Replaces FWPCA Form 188 which is obsolete, and PHS Form 416-5 which will not be used.