ASSISTANCE ID NO. ASSISTANCE ACTION

PRG DOC ID AMEND U.S. ENVIRONMENTAL PROTECTION AGENCY

 WASHINGTON, D.C. 20460 TYPE: Individual

 FELLOWSHIP AGREEMENT 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.

GENERAL INFORMATION

FELLOW SPONSOR

County:

Cong. Dist.:

Phone: Phone:

E-Mail: E-Mail:

The duration of this Fellowship will be months. This PROJECT PERIOD BUDGET PERIOD

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. 2030-0020

 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.