Form FEMA Form 119-25-4 FEMA Form 119-25-4 Student Stipend Agreement (Amendment)

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
STUDENT STIPEND AGREEMENT (AMENDMENT)

OMB Control No. 1660-0100
Expires: 04/30/2020

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 2 minutes. The burden estimate includes the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You are not
required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the
accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3172, Paperwork Reduction Project
(1660-0100) NOTE: Do not send your completed form to this address.
Privacy Act Statement
General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals applying for
student stipend reimbursement from the Federal Emergency Management Agency.
Authorities: Public Law 93-498, 15 U.S.C. 2206, 5 U.S.C. 301, 50 U.S.C. APP. 2253, E.O. 12127 and E.O. 12148, Public Law 81-920, section
201(e), Public Law 93-288, section 201(e), and Public Law 104-134.
Purposes and Uses: The purpose of the information requested on this document and any supporting documents is to facilitate the review,
approval, accounting, and reimbursement of funds for the expense of student attendance at the National Emergency Training Center (NETC),
the Mount Weather Emergency Assistance Center (MWEAC), or selected off campus locations.
Effects of Nondisclosure: Submission of the information is voluntary; however, failure to provide the requested information may result in a
delay in processing the reimbursement claim.
STUDENT'S NAME (Last, first, middle)
BUSINESS PHONE (Include area code)
MAILING ADDRESS
A student stipend agreement was approved for the above named individual in the amount of $

. Actual verified travel
cost have exceeded the original stipend payment. This amendment provides a stipend supplement for total actual travel cost. All other
provisions of the original stipend contract remain the same.
STUDENT CERTIFICATION
I certify that the round- trip costs from my home to NETC, MWEAC, or other off campus locations exceeded my original travel stipend by
$

, and I request reimbursement of that amount. Attached is documentary proof of the actual expense. I understand
that I must file for reimbursement within 60 days of start of course or my claim will be denied.
STUDENT'S SIGNATURE

DATE

DO NOT WRITE BELOW THIS LINE - FOR OFFICIAL USE ONLY
ACCOUNTING INFORMATION:
Initial Stipend:

Obligated This Agreement:

Total Obligation:

APPROVAL
RECOMMENDED

Signature
FEMA FORM 119-25-4 (05/16)

NOT RECOMMENDED

Date

APPROVED

Signature

DISAPPROVED

Date
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