Form DD 3067-12 DD 3067-12 Science, Mathematics, and Research for Transformation (S

CUI (when filled in)
OMB NO. 0704-0466
OMB approval expires
YYYYMMDD

Science, Mathematics, and Research for Transformation (SMART) Scholarship
Service Agreement
PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 4093, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 10 U.S.C. 133a, Under
Secretary of Defense for Research and Engineering; DoD Directive 5137.02, Under Secretary of Defense for Research and Engineering (USD(R&E));DoD
Instruction 1025.09, Science, Mathematics, and Research for Transformation Defense Education Program; and Executive Order 9397, Number System for
Federal Accounts Relating to Individual Persons, as amended.
PURPOSE: To record a service agreement for an individual receiving a SMART scholarship.
ROUTINE USES: While the information requested on this form is primarily intended to be used internally, in certain circumstances it may be necessary to
disclose this information externally, pursuant to 5 U.S.C. 552a(b)(3), including: to contractors, grantees, experts, consultants, students, and others performing or
working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency
function; and to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or the Federal Claims Collection Act of 1966
(31 U.S.C. 3701(a)(3)) to aid in the collection of outstanding debts owed to the Federal government, typically to provide an incentive for debtors to repay
delinquent Federal government debts by making these debts part of their credit records. A complete list of routine uses may be found in the applicable Privacy
Act System of Records Notice, DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information management System, found at
https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDA-14.pdf?ver=KO2ZkLWhxB3QCZoRTElMFA%3d%3d
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in SMART scholar being non-compliant with SMART policy, and
subject to possible dismissal.
The public reporting burden for this collection of information is estimated to average one hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense,
Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. Respondents should be aware that notwithstanding any
other provisions of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB
control number.
INSTRUCTION: Participants of the SMART Scholarship-For-Service Program (herein, the SMART Scholarship Program) are required to sign the SMART
Scholarship-For-Service Program Service Agreement (herein, the “Agreement”) that provides the terms and conditions for receiving financial benefits provided by
the SMART Scholarship Program.

1. SMART SCHOLARSHIP PROGRAM PARTICIPANT
FULL SOCIAL SECURITY NUMBER

FULL NAME (Last, First, MI)

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STREET NUMBER AND NAME

APARTMENT NUMBER

CITY

STATE

ZIP CODE

2. ACKNOWLEDGEMENT OF TERMINATION OF FINANCIAL ASSISTANCE AND OBLIGATION TO REFUND

I understand that if I withdraw from the SMART Scholarship Program prior to the completion of my service obligation , if I fail to fulfill my post-graduation service
obligation, if I am dismissed from the SMART Scholarship Program for failure to maintain satisfactory academic progress or failure to comply with any SMART
Scholarship Program policy or procedure as described in the SMART Scholar Handbook (and future revisions),or if I am removed from employment with my
Sponsoring Facility (SF) on the basis of misconduct before completing my post-graduation service obligation, the Agreement will be terminated and I will be in
default of the Agreement. I understand that if I am in default of the Agreement all financial assistance provided to me by the SMART Scholarship Program will
end. I understand that if I am in default of the Agreement that I am obligated to refund, to the United States Government, all funds that have been provided to me
or to others on my behalf or for my benefit under the Agreement, including all stipends, tuition, educational fees, health insurance allowances, book allowances,
internship support payments, and any other financial assistance provided by the United States pursuant to the Agreement. I understand that this obligation to
reimburse the United States is for all purposes a debt owed to the United States. Upon establishment of this debt, I understand that my failure to repay the debt
to the United States in a timely manner may result in my responsibilities for additional interest and/or penalties pursuant to Section 3717 of Title 31, U.S. Code.

3. AWARD INFORMATION
b. AWARD TYPE (X one)

a. COHORT YEAR

Recruitment

c. ACADEMIC INSTITUTION

Retention

d. DEGREE (X one)
BS

e. FIELD OF STUDY
BS/MS

MS

PhD

4. SPONSORING FACILITY
a. SPONSORING COMPONENT

b. SPONSORING FACILITY

c. LOCATION (City/State)

b. ENDING (YYYMMDD) (degree completion date)

c. TOTAL AWARD DURATION (Years)

5. DURATION OF AWARD
a. BEGINNING (YYYYMMDD)

6. AWARD AMOUNT
a. FULL-TIME ACADEMIC TUITION AND APPROVED EDUCATION FEES, DURING THE STANDARD ACADEMIC YEAR, AT THE FOLLOWING
ACADEMIC INSTIUTION:

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b. ANNUAL STIPEND RATE

c. RECRUITMENT INTERNSHIP SUPPORT PAYMENT RATE (if eligible, per current
SMART Scholar Handbook)

d. ANNUAL HEALTH INSURANCE ALLOWANCE RATE

e. ANNUAL MISCELLANEOUS ALLOWANCE RATE

7. SERVICE OBLIGATION (Initial in spaces provided)
Based on the currently calculated duration of my award, in accordance with Section 5c of the Agreement, I understand that I am required to
complete

years of post-graduation employment at my Sponsoring Facility (SF). I understand that if I do not fulfill my entire service obligation under
the SMART Scholarship Program, I will have breached the terms of the Agreement and will be in default of the Agreement, and that I will be dismissed from the
SMART Scholarship Program and may be responsible for the prompt repayment of all funds that have been provided to me or to others on my behalf or for my
benefit under the Agreement, in accordance with Section 2 of this Agreement. I further understand that my SF may have additional service requirements to that
of the SMART Scholarship Program. The SMART Scholarship Program service obligation is in addition to any other period for which I am obligated to serve in
the civil service of the United States.
I understand that the offer of civilian employment will be made by my SF upon completion of my academic degree as set forth in the Agreement. I
understand that this offer of civilian employment will be commensurate with Office of Personnel Management (OPM) and SF guidelines and standards, and that
my service obligation is to be served at my SF in a position and with a salary/benefits that meets these guidelines and standards at the time which the offer of
civilian employment is made. I understand that until I receive this offer of civilian employment from my SF in accordance with OPM and my SF’s guidelines and
standards, and that any representation, statements, or communications regarding compensation and benefits made prior to my offer of civilian employment made
by my SF is not binding.

8. COMPLIANCE OBLIGATION AND FULFILLMENT OF AGREEMENT (Initial in space provided)
I understand that I am required to fulfill the terms of the Agreement and comply with all SMART Scholarship Program policies and procedures set
forth in this Agreement and the SMART Scholar Handbook (to include future SMART Scholar Handbook revisions). I agree to obtain prior approval from the
SMART Scholarship Program before making any change under this Agreement or to my funded degree program (e.g., change of degree completion date,
change of degree pursued, change of academic institution, etc.). The Agreement, including the most recent version of the SMART Scholar Handbook constitutes
the full agreement between the parties, and any representation, statements, or communications not specifically incorporated herein, shall not be binding or of any
force or effect.

9. DISCLAIMERS (Initial in spaces provided)
I understand that all promises of payments to me or to others on my behalf or for my benefit pursuant to the SMART Scholarship Program and the

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Agreement are subject to the availability of funds.

I understand that the terms of the Agreement are severable. In the event that any part, term, or provision of the Agreement is deemed invalid or
otherwise unenforceable by a court of law with proper jurisdiction, such part, term, or provision shall be deemed severed from the Agreement and all remaining
parts, terms, and provisions in the Agreement shall not be affected and shall remain in full force and effect.

10. ACKNOWLEDGEMENT OF EMPLOYMENT STATUS (Multi-year recruitment participants only. Initial in spaces provided)
I understand that while I am participating in the SMART Scholarship Program prior to the start date of my civilian employment at my SF upon
completion of my academic degree, I am not an employee of the United States Government or any instrumentality thereof. I further understand, however, that,
while I am participating in a SMART Scholarship Program internship at a SF that I will be considered an employee of the United States Government solely for
certain, limited purposes relating to compensation for injuries occurring during the performance of approved internship activities and liability for tort claims, the
Privacy Act, and criminal conflicts of interest, pursuant to section 4143 of title 10, U.S. Code.
I expressly agree that I am neither entitled to nor expect any present or future salary, wages, or other benefits as a United States Government civilian
employee while completing a SMART Scholarship Program internship.
I agree to be bound by the laws and regulations applicable to interns and agree to participate in any training required by the SF, DoD laboratory,
installation, or unit for me to participate in the SMART Scholarship Program internship. I agree to follow all rules and procedures of the SF, DoD laboratory,
installation, unit, or any other place where I am participating in a SMART Scholarship Program internship.

11. CERTIFICATION BY SMART SCHOLARSHIP PROGRAM SCHOLAR
I certify that I have read and understand the conditions, terms, and requirements of the Agreement and the SMART Scholar Handbook and that I will comply with
them. I certify that I will be 18 years of age or older as of the SMART Scholarship Program award start date.
b. SIGNATURE
a. NAME (Last, First, Middle Initial)
c. DATE SIGNED (YYYYMMDD)

Legal Guardian Signature required if SMART Scholarship Program participant is under 18 years of age at time of award.
d. NAME (Last, First, Middle Initial)

e. SIGNATURE

f. DATE SIGNED (YYYYMMDD)

12. SPONSORING DOD COMPONENT ADMINSTERING OFFICE
a. NAME (Last, First, Middle Initial)

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b. SIGNATURE

CUI (when filled in)

c. DATE SIGNED (YYYYMMDD)

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