Form 3135-0112 NEA National Heritage Fellowships Acceptance Form & Inst

General Information and Instructions for

NATIONAL ENDOWMENT FOR THE ARTS

National Heritage Fellowships
Legal Name:
How would you like your name(s)
to appear on the press release?
(We willshare the press release
with you before posting.)

(last)

(first)

(middle initial)

(Ms./Mr./Dr.)

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

U.S. Citizenship:
Birth Date:

Native American
Alaska Native Tribal
Affiliation
(optional and if
applicable):

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

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currently valid U.S. Office of Management and Budget (OMB) control number.
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 to select persons to participate in the National
Endowment for the Arts’ application review process. Disclosure of this information may be made to
members of Congress and to the general public, upon request in accordance with the Freedom of
Information Act (5 U.S. C. 552). Personal biographical data including home address, home telephone
number, and social security number will not be released and is exempt from disclosure under FOIA
exemption (b)(6).
OMB No. 3135-0112 Expires TBD