5770-8 Fellowship Agreement

U.S. ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

Form Approved
OMB Control No. 2030-0020

FELLOWSHIP AGREEMENT
NOTE: The Fellowship Agreement must be completed in original and three copies. The original and first two copies must be returned to the Grants Administration Division within 3 weeks after receipt
or within any extension of time as may be granted by EPA. Except as may be otherwise provided, no costs may be incurred prior to the execution of the Fellowship Agreement by parties thereto.
Receipt of a written refusal, or failure to return the properly executed document within the prescribed time, will result in the automatic termination of consideration of the fellowship offer by the
Agency. Any amendment to the Fellowship Agreement by the fellow subsequent to the document being signed by the Award Official shall void the Fellowship Agreement.
PART I
1.

GENERAL INFORMATION
FELLOWSHIP ADMINISTRATION DATA

a. STATUE REFERENCE

2.

b. REGULATION REFERENCE

APPROPRIATION AND ACCOUNTING DATA

a. APPROPRIATION

b. ACCOUNT NUMBER

c. FELLOWSHIP PROGRAM

c. OBJECT CLASS CODE

3.

4.

AWARD APPROVAL OFFICE

a. ORGANIZATION

a. ORGANIZATION

b. ADDRESS

b. ADDRESS

5.

ISSUING OFFICE

PROJECT OFFICER (Federal Contact)

a. NAME

d. ADDRESS

b. TITLE

c. TELEPHONE NUMBER (Include Area Code)

6.

FELLOW
b. ADDRESS

a. NAME

7.

SPONSOR
d. ADDRESS

a. NAME

b. TITLE

c. TELEPHONE NUMBER (Include Area Code)

8. AMOUNT

a. TUITION AND FEES

PAID TO
INSTITUTION

$

b. BOOKS AND SUPPLIES (May not exceed $250.)

PAID DIRECT TO
FELLOW

$

c. STIPEND

$
TOTAL AMOUNT OF FELLOWSHIP

$

9. DURATION (Approved dates of fellowship: 12 months or less):
FROM:

TO:

10. PAYEE (For Institutional Allowances

11. FELLOW’S NAME AND ADDRESS (For stipend check)

a. NAME

a. NAME

b. TITLE

b. ADDRESS

c. ADDRESS

EPA Form 5770-8 Replaces Form FWPCA_189 (7-98) which is obsolete and PHS 416.4 which will not be used.

PART II

SPECIAL CONDITIONS (If any)

(Continue on blank sheet if more space is needed)
PART III

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
[FELLOW]
[FELLOWSHIP AMOUNT]
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 (40 CFR, Part 46)
and of the provisions of this agreement (Parts I thru III). 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

TITLE

DATE

BY FELLOW
SIGNATURE
EPA Form 5770-8 (Reverse)

TYPED NAME

DATE

Paperwork Reduction Act Burden Statement
The public reporting and record keeping 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 estimate, 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.

EPA Form 5770-8