ASSISTANCE ID NO. ASSISTANCE ACTION PRG DOC ID AMEND U.S. ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, D.C. 20460 TYPE: Individual FELLOWSHIP PROGRAM STATUS 

### FELLOWSHIP AGREEMENT

AWARD DATE MAIL DATE

NOTE: The Fellowship Agreement must be completed and returned to Grants Administration Division within 3 weeks after receipt o r 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 Agreemen t. This Fellowship Award contains information on fellowship applicants , which is protected by th e 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. GENERAL INFORMATION FELLOW SPONSOR

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

Phone: Phone: E-Mail: E-Mail: AWARD APPROVAL OFFICE ISSUING OFFICE U.S. Environmental Protection Agency 1200 Pennsylvania Avenue, NW Washington, DC 20460 Grants Administration Division U

. S

. Environmental Protection Agency 1200 Pennsylvania Avenue, NW Washington, DC 20460 PAYEE (FOR INSTITUTIONAL ALLOWANCE) FELLOW'S NAME AND ADDRESS (FOR STIPEND CHECK) OMB Control No. 20 30

- 0020 Approval expires 04 / 30 / 2012

EPA Form 5770-8 (Rev 04/2012)AWARD AMOUNT

FUNDS FORMER AWARD THIS ACTION AMENDED TOTAL EPA Amount $

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 offers a Fellowship to for all approved costs up to and not exceeding $ for the support of the effort described in application dated (including all application modifications) 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

The public reporting and recordkeeping burden for this collection of information is estimated to average 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, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 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.