5770-08 Fellowship Agreement

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 1 hour 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.

ASSISTANCE ID NO.
PRG DOC ID
AMEND

U.S. ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, D.C. 20460

FELLOWSHIP AGREEMENT

ASSISTANCE ACTION
TYPE: Individual

FELLOWSHIP PROGRAM

STATUS

AWARD DATE

MAIL DATE

NOTE: The Fellowship Agreement must be completed and returned to Grants Administration Division within 3 weeks after receipt or

within any extension of time as may be granted by EPA. Except as may be approved by EPA, no costs may be incurred prior
to the award date of this Agreement. Receipt of a written refusal, or failure to return the properly executed document within
the prescribed time, may result in termination of the fellowship offer by the Agency. Any modification to the Fellowship
Agreement by the fellow subsequent to the document being signed by the award official shall void the Fellowship Agreement.
This Fellowship Award contains information on fellowship applicants, which is protected by the Privacy Act of 1974. If you
receive this form in error, do not copy or distribute. Unauthorized access, use or disclosure of this data subjects violators to
criminal penalties.

FELLOW

GENERAL INFORMATION

SPONSOR

County:
Cong. Dist.:
Phone:
Phone:
E-Mail:
E-Mail:
The duration of this Fellowship will be
months. This
PROJECT PERIOD
Fellowship must be activated within 90 days after the date
of the award.
AMOUNT
FROM
THIS ACTION
$
$
A. Tuition and Fees (Paid to Institution)
$
$
B. Books and Supplies (Paid Direct)
$
$
C. Stipend (To Fellow)
Total Amount of Fellowship
PROJECT OFFICER

Phone:
E-Mail:

AWARD APPROVAL OFFICE
U.S. Environmental Protection Agency
1200 Pennsylvania Avenue, NW
Washington, DC 20460
PAYEE

(FOR INSTITUTIONAL ALLOWANCE)

EPA Form 5770-8 (Rev 04/2012)

$

BUDGET PERIOD

$

TO

$
$

$
$
GRANT SPECIALIST

Phone:
E-Mail:

ISSUING OFFICE
Grants Administration Division
U.S. Environmental Protection Agency
1200 Pennsylvania Avenue, NW
Washington, DC 20460
FELLOW'S NAME AND ADDRESS (FOR STIPEND CHECK)

AWARD AMOUNT
FUNDS
EPA Amount

FORMER AWARD

THIS ACTION

$

AMENDED TOTAL

APPROPRIATION AND ACCOUNTING DATA
Site Name

DCN

FY

Approp.
Code

Budget Org.

PRC

Object
Class

Site/Project

Cost
Organization

Obligation /
Deobligation

Regulatory Authority:
STATUTORY AUTHORITY

ASSISTANCE PROGRAM (CFDA)

OFFER AND ACCEPTANCE
The United States of America, acting by and through the U.S. Environmental Protection Agency (EPA), hereby
for all approved costs up to and not exceeding $
for the
offers a Fellowship to
(including all application modifications)
support of the effort described in application dated
included herein by reference.
This fellowship Agreement is subject to applicable U.S. Environmental Protection Agency statutory provisions, fellowship
regulations (____) and of the provisions of this agreement. The Fellow also agrees that funds awarded will
be used solely for the purposes of the program as approved.
THE UNITED STATES OF AMERICA BY THE U.S. ENVIRONMENTAL PROTECTION AGENCY
AWARD OFFICIAL
SIGNATURE

TYPED NAME AND TITLE

DATE

FELLOW
SIGNATURE

TYPED NAME

DATE