RSA Exit Certificate

REHABILITATION SERVICES ADMINISTRATION (RSA) SCHOLAR EXIT CERTIFICATION FORM

Instructions for Grantees/RSA Scholars:

Completion of an exit certification form is required regardless of whether the scholar graduates earning a degree, certificate of completion, completes all coursework to include specific program requirements, i.e., (internship/practicum), or voluntarily/involuntarily withdraws. An exit certificate must be accurately completed, signed, and dated by the RSA (Long-Term Training) scholar and RSA Project Director or other appropriate grantee official, as the scholar exits the training program. The RSA Project Director is responsible for uploading the completed exit certificate in the RSA Payback Information System (PIMS).

There are three distinctions of the scholar who exits: 1) the scholar who graduates or receives a certificate of completion (Form I), 2) the scholar who voluntarily or involuntarily withdraws from the program (Form 2), and 3) the scholar who voluntarily or involuntarily withdraws from the program without completing one academic year of training (Form 3). Only one form should be completed; consequently, please pay careful attention to ensure that you complete the form that appropriately applies to the scholar’s reason for exiting. Any questions regarding the appropriate form to use may be discussed with the RSA project officer.

EXIT TERMS AND CONDITIONS

Form #1 Scholars who graduate or receive a certificate of completion

The below is applicable and must be completed by the scholar who fully met the terms and conditions of the training that was provided through graduation, program exit, or completion of a certificate.

As an RSA training scholarship recipient, I, (insert name of scholar), Social Security # XXX-XX-XXXX acknowledge the following information as being true and accurate:

(1) I received scholarship funds from (insert name of institution) under PR/Award # (insert grant number) awarded by the U.S. Department of Education for training received in the (insert name of program).

(2) I understand that I must work for (enter the amount of time in months or years) to satisfy the work requirements of the Scholarship Agreement.

(3) The total amount of scholarship assistance received from this institution, under PR/Award # (insert grant number above), that is subject to the work-or-repay provisions of Federal statutes and regulations is $ (enter the total amount the scholar received).

(4) I understand that I have a two-year grace period from the date of graduation to secure qualifying employment.

(5) The work requirements must be satisfied within (insert number of years) after completion of the training or exiting the program. To meet the full work obligation, appropriate employment must be obtained no later than (enter the date) and completed no later than (enter the date).

(6) I understand that I must inform the institution that awarded the scholarship of any change in my name, address, and employment status. I am also responsible for documenting and entering my employment in the RSA PIMS annually to indicate how I am satisfying the terms of my scholarship agreement until such time as the work obligation has been satisfied. Failure to do so may result in payback of the stipend including interest and costs of collection as provided in 34 CFR 386.43.

(7) If I fail to abide by the terms and conditions of this exit certification form causing my status to change to a scholar in repayment, I understand that payback including interest and costs of collection as provided in 34 CFR 386.43 will be managed by the U.S. Department of Education’s Accounts Receivable and Bank Management Division and/or the U.S. Department of Treasury’s Centralized Receivables Service.

(8) I acknowledge that I have received a copy of my signed Scholarship Agreement and this Exit

Certification Form, both of which outline the work-or-repay requirements stipulated in Federal

regulations, and I understand my obligations as an RSA scholarship recipient. Additional information on the work-or-repay provisions may be found in Part 386 of Title 34 of the Code of Federal Regulations and in the Long-Term Training Scholarship Manual, both of which have been made available to me, if requested, by the institution that provided the training.

________________________________ ___________________

Signature of Scholar Date

___________________________ ___________________

Signature of Project Director Date

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority for collecting the requested information about the scholar is P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. We request the scholar’s educational information pertinent to the RLTT scholarship grant received whether provided by the scholar, grantee, or other entity, including personally identifiable information (PII), under this authority in order to accurately track the scholar’s records and to differentiate the scholar’s financial obligation from other scholars who may have the same name. The scholar’s participation in the RLTT Program is voluntary, but you must provide the requested information, including the scholar’s PII, in order for the student to participate in the RLTT Program. The information will be used to ensure that recipients of scholarships provided with funds under the Rehabilitation Act meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in the scholar’s records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the computer matching requirements of the Privacy Act, under a computer matching agreement.

The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may also send this information to law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is 1820-0617.  Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is mandatory under P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact Corinna Stiles, Chief, Training Programs Unit at (202) 245-6162 or via email at [email protected] directly.

RSA SCHOLAR

EXIT CERTIFICATION FORM

Instructions for Grantees/RSA Scholars:

Completion of an exit certification form is required regardless of whether the scholar graduates earning a degree, certificate of completion, completes all coursework to include specific program requirements, i.e., (internship/practicum), or voluntarily/involuntarily withdraws. An exit certificate must be accurately completed, signed, and dated by the RSA (Long-Term Training) scholar and RSA Project Director or other appropriate grantee official, as the scholar exits the training program. Completion of an exit certification form is required regardless of whether the scholar graduates earning a degree, certificate of completion, completes all coursework to include specific program requirements, i.e., (internship/practicum), or voluntarily/involuntarily withdraws. The RSA Project Director is responsible for uploading the completed exit certificate soon after signing in the RSA Payback Information System (PIMS).

There are three distinctions of the scholar who exits: 1) the scholar who graduates or receives a certificate of completion (Form I), 2) the scholar who voluntarily or involuntarily withdraws from the program (Form 2), and 3) the scholar who voluntarily or involuntarily withdraws from the program without completing one academic year of training (Form 3). Only one form should be completed; consequently, please pay careful attention to ensure that you complete the form that appropriately applies to the scholar’s reason for exiting. Any questions regarding the appropriate form to use may be discussed with the RSA project officer.

EXIT TERMS AND CONDITIONS

Form #2 Scholars who voluntarily or involuntarily withdraw from the program

The below is applicable and must be completed by the scholar who voluntarily drops out/withdraws or is involuntarily withdrawn prior to completing the program.

As an RSA training scholarship recipient, I, (insert name of scholar), Social Security # XXX-XX-XXXX acknowledge the following information as being true and accurate:

(1) I received scholarship funds from (insert name of institution) under PR/Award # (insert grant number) awarded by the U.S. Department of Education for training received in the (insert name of program).

(2) I understand that because I voluntarily dropped out/withdrew or was involuntarily withdrawn prior to completing the program, I must work-or-repay the scholarship assistance pursuant to provisions of Federal statutes and regulations beginning one month from the date of exit.

(3) If I secure qualifying employment one month from my date of exit, I understand that I must work for (enter the amount of time in months or years) to satisfy the work requirements of the Scholarship Agreement, otherwise cash repayment will begin one month from the date of exit. To meet the full work obligation, appropriate employment must be obtained no later than (enter the date) and completed no later than (enter the date).

(4) The total amount of scholarship assistance received from this institution, under PR/Award # (insert grant number), that is subject to the work-or-repay provisions of Federal statutes and regulations is $ (enter the total amount the scholar received).

(5) I understand that I must inform the institution that awarded the scholarship of any change in my name, address, and employment status. I am also responsible for documenting and entering my employment in the RSA PIMS annually to indicate how I am satisfying the terms of my scholarship agreement until such time as the work obligation has been satisfied. Failure to do so may result in payback of the stipend including interest and costs of collection as provided in 34 CFR 386.43.

(6) If I fail to abide by the terms and conditions of this exit certification form or maintain qualifying employment until I complete my required service obligation causing my status to change to a scholar in repayment, I understand that payback including interest and costs of collection as provided in 34 CFR 386.43 will be managed by the U.S. Department of Education’s Accounts Receivable and Bank Management Division and/or the U.S. Department of Treasury’s Centralized Receivables Service.

(7) I acknowledge that I have received a copy of my signed Scholarship Agreement and this Exit

Certification Form, both of which outline the work-or-repay requirements stipulated in Federal

regulations, and I understand my obligations as a scholarship recipient. Additional information on the work-or-repay provisions may be found in Part 386 of Title 34 of the Code of Federal Regulations and in the Long-Term Training Scholarship Manual, both of which have been made available to me, if requested, by the institution that provided the training.

________________________________ ___________________

Signature of Scholar Date

___________________________ ___________________

Signature of Project Director Date

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority for collecting the requested information about the scholar is P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. We request the scholar’s educational information pertinent to the RLTT scholarship grant received whether provided by the scholar, grantee, or other entity, including personally identifiable information (PII), under this authority in order to accurately track the scholar’s records and to differentiate the scholar’s financial obligation from other scholars who may have the same name. The scholar’s participation in the RLTT Program is voluntary, but you must provide the requested information, including the scholar’s PII, in order for the student to participate in the RLTT Program. The information will be used to ensure that recipients of scholarships provided with funds under the Rehabilitation Act meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in the scholar’s records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the computer matching requirements of the Privacy Act, under a computer matching agreement.

The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may also send this information to law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is 1820-0617.  Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is mandatory under P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact Corinna Stiles, Chief, Training Programs Unit at (202) 245-6162 or via email at [email protected] directly.

RSA SCHOLAR

EXIT CERTIFICATION FORM

Completion of an exit certification form is required regardless of whether the scholar graduates earning a degree, certificate of completion, completes all coursework to include specific program requirements, i.e., (internship/practicum), or voluntarily/involuntarily withdraws. An exit certificate must be accurately completed, signed, and dated by the RSA (Long-Term Training) scholar and RSA Project Director or other appropriate grantee official, as the scholar exits the training program. Completion of an exit certification form is required regardless of whether the scholar graduates earning a degree, certificate of completion, completes all coursework to include specific program requirements, i.e., (internship/practicum), or voluntarily/involuntarily withdraws. The RSA Project Director is responsible for uploading the completed exit certificate soon after signing in the RSA Payback Information System (PIMS).

There are three distinctions of a scholar who exits: 1) the scholar who graduates or receives a certificate of completion (Form I), 2) the scholar who voluntarily or involuntarily withdraws from the program (Form 2), and 3) the scholar who voluntarily or involuntarily withdraws from the program without completing one academic year of training (Form 3). Only one form should be completed; consequently, please pay careful attention to ensure that you complete the form that appropriately applies to the scholar’s reason for exiting.

EXIT TERMS AND CONDITIONS

Form #3 Scholar who voluntarily or involuntarily withdraw from the program without completing one academic year of training

The below is applicable and must be completed by the scholar who voluntarily drops out/withdraws or is involuntarily withdrawn prior to completing the program without completing one academic year of training.

As a training scholarship recipient, I, (insert name of scholar), Social Security # XXX-XX-XXXX acknowledge the following information as being true and accurate:

(1) I received scholarship funds from (insert name of institution) under PR/Award # (insert grant number) awarded by the U.S. Department of Education for training received in the (insert name of program).

(2) I understand that because I voluntarily dropped out/withdrew or was involuntarily withdrawn prior to completing the program, and did not complete one academic year of training, I must repay the scholarship assistance through cash repayment (34 CFR 386.40(b) (1)) beginning one month from the date of exit.

(3) The total amount of scholarship assistance received from this institution, under PR/Award # (insert grant number above), that is subject to the repay provisions of Federal statutes and regulations is $XXX.

(4) I understand that payback including interest and costs of collection as provided in 34 CFR 386.43 will be managed by the U.S. Department of Education’s Accounts Receivable and Bank Management Division and/or the U.S. Department of Treasury’s Centralized Receivables Service.

(5) I acknowledge that I have received a copy of my signed Scholarship Agreement and this Exit

Certification Form, both of which outline the work-or-repay requirements stipulated in Federal

regulations, and I understand my obligations as a scholarship recipient. Additional information on the work-or-repay provisions may be found in Part 386 of Title 34 of the Code of Federal Regulations and in the Long-Term Training Scholarship Manual, both of which have been made available to me, if requested, by the institution that provided the training.

________________________________ ___________________

Signature of Scholar Date

___________________________ ___________________

Signature of Project Director Date

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority for collecting the requested information about the scholar is P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. We request the scholar’s educational information pertinent to the RLTT scholarship grant received whether provided by the scholar, grantee, or other entity, including personally identifiable information (PII), under this authority in order to accurately track the scholar’s records and to differentiate the scholar’s financial obligation from other scholars who may have the same name. The scholar’s participation in the RLTT Program is voluntary, but you must provide the requested information, including the scholar’s PII, in order for the student to participate in the RLTT Program. The information will be used to ensure that recipients of scholarships provided with funds under the Rehabilitation Act meet specific statutory and regulatory requirements, including service obligation fulfillment or repayment of financial obligation.

The information in the scholar’s records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the computer matching requirements of the Privacy Act, under a computer matching agreement.

The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may also send this information to law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is 1820-0617.  Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is mandatory under P.L. 114-95 section 302 (b) of the Rehabilitation Act of 1973, as amended by the Workforce Innovation and Opportunity Act (WIOA), and the implementing regulations, CFR 386. If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application or survey, please contact Corinna Stiles, Chief, Training Programs Unit at (202) 245-6162 or via email at [email protected] directly.