DD Form 2753 National Security Education Program (NSEP) Service Agree

CUI (when filled in)

NATIONAL SECURITY EDUCATION PROGRAM (NSEP)
SERVICE AGREEMENT REPORT (SAR) FOR SCHOLARSHIP AND FELLOWSHIP AWARDS

OMB No. 0704-0368
OMB approval expires:
XX/XX/XXXX

The public reporting burden for this collection of information is estimated to average ## hours/minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense,
Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any
other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number. SEND THIS COMPLETED FORM BY MAIL, FAX OR E-MAIL TO: National Security Education Program, 4800 Mark Center Drive, Suite 08G08,
Alexandria, VA 22350-7000
Fax: (703) 692-2615 For questons, call (571)-256-0711 or E-mail: [email protected]
PRIVACY ACT STATEMENT
AUTHORITY: 50 U.S.C. 1901, David L. Boren National Security Education Act of 1991; DoD Instruction (DoDI) 1025.02, National Security Education Program
(NSEP) and NSEP Service Agreement; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): To document recipient's status and compliance in fulfilling the service requirement.
ROUTINE USE(S): To the U.S. Department of Treasury for individuals who are non-compliant with Service Agreement and who fail to pay back awards have their
name, address, and taxpayer identification number (SSN); the amount, status, and history of the claim sent to the U.S. Treasury for collection. Additional routine
uses are listed in the applicable system of records notice, DHRA 09 located at http://dpclo.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/
tabid/6797/Article/6691/dhra-09.aspx.
DISCLOSURE: Voluntary; however, failure to furnish the requested information may result in NSEP not being able to process your request for service credit and
you may be required to repay the amount of your award, plus interest.

SECTION I - DEMOGRAPHIC DATA
3. SOCIAL SECURITY NUMBER
(Last 4 digits)

2. FORMER NAME

1. RECIPIENT NAME (Last, First, Middle Initial)

4. CURRENT CONTACT INFORMATION
a. STREET AND APARTMENT/SUITE NUMBER

e. E-MAIL ADDRESS

5. PERMANENT CONTACT INFORMATION
a. STREET AND APARTMENT/SUITE NUMBER

b. CITY

c. STATE

f. HOME TELEPHONE NUMBER (Include area
code)

g. SECONDARY OR WORK TELEPHONE
NUMBER (Include area code)

b. CITY

c. STATE

DRAFT

d. ZIP CODE

d. ZIP CODE

e. HOME TELEPHONE NUMBER (Include area code)

SECTION II - RECIPIENT'S STATUS Items 7 through 12 (Complete Items 18 and 21 in Section IV.)
6. I have been engaged in work in fulfillment of my requirement during this reporting period. (Complete Items 13 through 21 in Sections III and IV.)
7. I have not graduated from nor terminated enrollment in the degree program pursued while receiving NSEP support. My anticipated
graduation date is (Month/Year)

.

8.a. I am furthering my education and request a deferral of the service requirement until I complete my
degree program at
and my anticipated graduation date is (Month/Year)

(Institution); my expected start date is (Month/Year)
.

b. I am furthering my education and do not request a deferral of the service requirement. My anticipated graduation date is (Month/Year)
.
9. I have not yet obtained employment in fulfillment of my service requirement during this reporting period.
10. I request a one year extension, as the time for completing my service requirement has expired. (Submit detailed plan outlining how you
plan to fulfill your service requirement during the extension period).
11. I request a waiver from my service requirement. (Explain grounds for waiver on a separate piece of paper and attach to SAR. Please note that
waivers are granted only in extreme cases.)
12. I request to repay my award in lieu of fulfilling my service requirement.

DD FORM 2753, 20210924 DRAFT
PREVIOUS EDITION IS OBSOLETE.

CUI (when filled in)

Controlled by: DLNSEO
Page
CUI Category: PRIV
Distribution/Dissemination Control: FEDCON
POC: [email protected]

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CUI (when filled in)
SECTION III - DESCRIPTION OF SERVICE
14. NUMBER OF HOURS PER
WEEK

13. DATES
a. FROM (MM/DD/YYYY)

15. TYPE OF EMPLOYMENT (X one)

b. TO (MM/DD/YYYY)

a. FEDERAL

c. CONTRACTOR

b. EDUCATION

d. ACTIVE DUTY MILITARY

16. SUPPLEMENTAL INFORMATION (X all that apply)
a. I use a foreign language in my position. (Explain:)
b. My position requires a security clearance. (If so, type:)
c. Which hiring authority were you appointed under? (This information can be found in the "Legal
Authority" box (5-D) on the SF-50 associated with your initial hire)
17. DESCRIPTION OF DUTIES (Please spell out all acronyms.)
a. DEPARTMENT/ORGANIZATION
INSTITUTION

b. BUREAU/AGENCY

c. OFFICE

d. TITLE

e. Describe the work you are doing to fulfill your NSEP service requirement and how it relates to U.S. national security. If you are eligible to work in higher
education and are doing so, describe the connection with your NSEP-funded study.

SECTION IV - CERTIFICATION (NOTE: Service will NOT be approved without supervisor verification and signature.)
18. I have activated and updated my resume on NSEPNET.

a. YES

b. NO

19. CONTACT INFORMATION FOR EMPLOYING ORGANIZATION
a. NAME OF EMPLOYING ORGANIZATION

b. SUPERVISOR'S TELEPHONE NUMBER (Include area code)

c. STREET ADDRESS

d. CITY

g. SUPERVISOR's E-MAIL ADDRESS

20. SUPERVISOR VERIFICATION
a. SUPERVISOR'S NAME (Last, First, Middle Initial)

DRAFT

e. STATE

f. ZIP CODE

b. TITLE

c. SUPERVISOR'S SIGNATURE

d. DATE SIGNED

21. I certify, to the best of my knowledge, that all of the above statements are true, complete, and correct. I agree to provide additional information as
requested. I understand that my work in fulfillment of the service agreement must be wholly completed within five years of my first date of service
unless an approved deferral or extension has been granted. I understand that my service requirement is completed upon receipt of formal
notification from NSEP. I agree to submit this form annually until my service is complete, or every six months if granted an extension. I will notify
NSEP within 10 days if my contact information changes.
a. NAME

b. SIGNATURE

c. DATE SIGNED

b. SIGNATURE

c. DATE SIGNED

SECTION V - FOR NSEP USE ONLY
22. ACTION

23.a. NAME OF NSEP OFFICIAL

24. LENGTH OF
REQUIREMENT

25. MONTHS PREVIOUSLY 26. APPROVED
APPROVED
MONTHS

DD FORM 2753, 20210621 DRAFT
PREVIOUS EDITION IS OBSOLETE.

27. MONTHS
REMAINING

CUI (when filled in)

28. YEAR OF
AWARD

29. X
S

LF

F

EHLS
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