5770-9 EPA Fellowship Termination Notice

OMB Control No. 2030-0020
U.S. ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

EPA FELLOWSHIP TERMINATION NOTICE
DATE OF THIS NOTICE:

FELLOWSHIP NUMBER

TERMINATION DATE

TYPE OF FELLOWSHIP

TO:

INSTRUCTIONS:
This form should be completed
immediately after termination of
fellowship tenure. Please return to:
U.S. Environmental Protection Agency
Grants Administration Division
Grants Operations Branch
Washington, DC 20460

NAME OF FELLOW

INSTITUTION

Your Fellowship terminates on the date indicated above. To complete our files, please provide the following information and two reprints of any
publication of work done under the fellowship, when available.
MAILING ADDRESS AFTER TERMINATION OF FELLOWSHIP (Future address changes appreciated)

DEGREE SOUGHT (Ph.D., M.S.,
None)

DATE RECEIVED OR
EXPECTED

REMARKS (Provide any constructive criticism or advice from you and your sponsor that would enable us to improve the operation of the EPA
Fellowships program. Use otherwise or additional sheet, if necessary.)

CERTIFICATION
This is to certify that the individual named above terminated his fellowship activities at the above named institution on the date indicated below.
DATE TERMINATED

EPA Form 5770-9 (7-2009)

SIGNATURE OF SPONSOR OR AUTHORIZED OFFICIAL

TITLE

REPLACES FORM FWQA 190-1 (9-70) WHICH IS OBSOLETE AND FORM PHS 416-7 WHICH WILL NOT BE USED

Paperwork Reduction Act Burden
Statement
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.
.