SMART Scholarship SMART Service Agreement Amendment Request

SMART Scholarship-for-Service Program

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SCIENCE, MATHEMATICS, AND RESEARCH FOR TRANSFORMATION (SMART) SERVICE
AGREEMENT AMENDMENT REQUEST

OMB No.
OMB Approval expires

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 2192a, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 5 U.S.C. 3304, Competitive service
examinations; 20 U.S.C. 17, National Defense Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPLE PURPOSE(S): To record a service agreement amendment for an individual receiving a SMART scholarship.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To academic institutions for the
purpose of providing progress reports for applicants and participants; 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)). The purpose of this disclosure is 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;
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure When Requesting Information
Routine Use, Disclosure of Requested Information Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the
National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use.
The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices
may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
The applicable Privacy Act System of Records Notice is DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information Management
System, found at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570592/dusda-14.aspx
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in SMART participant not being compliant with SMART policy and subject
to possible dismissal.

Instructions – SMART Scholarship Program Participants (SSPPs) requesting to amend an existing SMART Service Agreement must submit this request.
Changes approved pursuant to this Service Agreement Amendment Request modify only the specific terms of the SMART Service Agreement amended. The
remainder of the SMART Service Agreement remains in full force and effect.

SECTION 1 – SMART SCHOLARSHIP PROGRAM PARTICIPANT AWARD INFORMATION
Name (LAST, First, MI):
Cohort Year:
Phone:
Email:
Awardee Type:
Recruitment
Retention
Sponsoring Service:
Sponsoring Facility:
Location (city/state):
Degree Level Funded by SMART:
B.S.
B.S./M.S.
M.S.
Field of Study:
Academic Institution:
*
**
Degree Completion Date :
Degree Conferral Date :

Ph.D.

Notes: * Degree completion date - date on which an individual completes all degree requirements. This generally occurs prior to degree conferral and is not set forth on official transcripts.
** Degree conferral date - date on which a degree is bestowed upon an individual. This is set forth on the official transcript reflecting the degree earned and may occur after degree
completion.

SECTION 2 – TYPE OF AMENDMENT ( X one) See following pages for instructions and required documentation.
Academic Institution

Additional Enrollment

Additional Tuition

Award Length Decrease

Award Length Increase

Award Type

Deferral of Phase 2

Degree Level

Field of Study

Full Time Enrollment

Internship

Leave of Absence

Outside Employment

Sponsoring Facility

Stipend Rate Increase

Withdrawal

Other (descriptive term) _________________________________________

SECTION 3 – REQUEST DETAILS (For ALC, complete Revised Degree Completion/Conferral Dates)
Revised Degree Completion Date:

Revised Degree Conferral Date:

SECTION 4 – COMPLIANCE – (initial next to each)
______I understand that, if denied, I must comply with the SMART Service Agreement as granted.
______I understand that, if denied or if I default on any term or condition of this Service Agreement Amendment, I may be dismissed from the program and may be
responsible for the prompt refund of all federal funds expended under my award including all stipends, tuition, approved related educational fees, health insurance
allowances, book allowances, internship support payments, and any other financial assistance provided by the United States under my award, plus interest on that
amount from the date of the award at the prescribed rate under Section 3717 of Title 31, penalties and all other amounts associated with collection.
______I understand that if I fail to make a prompt refund, the United States may collect such amounts as indebtedness to the United States.

SECTION 5 – CERTIFICATION BY SMART SCHOLARSHIP PROGRAM PARTICIPANT
In signing my SMART Service Agreement Amendment, I certify that all information is true and accurate to the best of my knowledge. I have attached/completed
additional requests and/or supporting documentation, as applicable. I understand that approval of my Service Agreement Amendment Request is determined on a
case-by-case basis and at the discretion of the SMART Scholarship Program. I certify that I understand that any approved award length increase incurs an additional
commensurate service commitment. I certify that I have read and understand the conditions, terms, and requirements of this Service Agreement Amendment and
that I will comply with them.

NAME (Last, First, Middle)

DATE SIGNED (MMDDYYYY)

SIGNATURE

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----------------------------------------------DO NOT WRITE BELOW THIS DOTTED LINE / SMART SCHOLARSHIP PROGRAM USE ONLY-------------------------------SECTION 6 – SMART SCHOLARSHIP PROGRAM REVIEW
SMART Participant ID number:
Service Liaison Verification:
N/A
Is there a change in award cost
No
associated with this request?
Cohort Administrator Name:
SMART Program
Request Approved
Decision:
NAME (Last, First, Title)

Attached

SF supports
Yes: Increase in cost
Yes: Decrease in cost

SF does not support
Amount:
Date processed:

Funding Approved
Funding Denied
SIGNATURE

Request Denied

ACKNOWLEDGED (FOR

WITHDRAWAL ONLY)

DATE SIGNED (MMDDYYYY)

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Instruction to the SMART Scholarship Program Participant (SSPP):
Instructions for requests to amend the SMART Service Agreement (SSA) are detailed in the chart below. The SAAR is incomplete without the
required documentation.
Amendment Request

 Academic Institution

Instruction
SSPPs who request to change their awarded Academic
Institution or whose Sponsoring Facilities request them to
change.

 Additional Enrollment

Applies to:
1. Year-round enrollment and/or completion of coursework
required by program/institution.
2. Required coursework during summer or winter terms
without tuition.
3. Elective coursework during summer or winter terms without
tuition.

 Additional Tuition

Applies to:
1. Year-round enrollment and/or completion of coursework
required by program/institution.
2. Required coursework during summer or winter terms.
3. Elective coursework during summer or winter terms.

 Award Length Decrease

SSPPs who request to decrease their award length are
recommended to do so one term prior to the proposed degree
completion date.

 Award Length Increase

SSPPs who request to increase their award length are
recommended to do so one term prior to the original degree
completion date.

 Award Type

Applies to:
SSPPs who are directed to change their program status from
Recruitment to Retention or Retention to Recruitment.

Required Documentation
1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
2. Documentation that the new institution accepts you
into the program; and
3. Submit a Revised Degree Completion Plan.
1. If the coursework and/or enrollment is required for
degree completion, and cannot be taken another
time, provide a letter on official university letterhead
from your research advisor, academic advisor, or
appropriate dean of the academic institution
confirming the need;
2. If the course can be taken during the Fall/Spring term,
provide written statement explaining the extenuating
circumstances for this request; and
3. Documentation verifying there is no cost associated
with this request.
1. If the coursework and/or enrollment is required for
degree completion, and cannot be taken another
time, provide a letter on official university letterhead
from your research advisor, academic advisor, or
appropriate dean of the academic institution
confirming the need;
2. If the course can be taken during the Fall/Spring term,
provide written statement explaining the extenuating
circumstances for this request; and
3. Include documentation of the cost associated with
this request.
1. Letter on official letterhead from a research advisor,
academic advisor, or appropriate dean of your
academic institution:
a.
Confirming the new date which you will have
completed all educational requirements for your
degree completion.
b. Confirmation of a new conferral date;
2. Signed personal statement detailing the circumstances
causing the decrease in degree completion and
confirmation that you have discussed the need for the
change with the SF; and
3. Submit the Revised Degree Completion Plan.
1. Letter on official letterhead from a research
advisor, academic advisor, or appropriate dean of
your academic institution confirming:
a.
Extenuating circumstance that caused the delay
in degree completion including dates and steps
taken to mitigate risks;
b. Steps remaining prior to degree completion and
when those milestones will be met; and
confirmation that you are capable of
completing the degree in accordance with
the proposed award length change.
2. Signed personal statement detailing:
a.
Extenuating circumstances causing the delay in
degree completion, including dates;
b. Steps taken to mitigate risks and/or manage the
issue causing the delay;
c.
Steps remaining prior to degree completion;
d. Confirmation that you have discussed the need
for the change with the SF; and
e. Confirmation if outside funding sources are
assisting in funding the remainder of the degree.
3. Submit the Revised Degree Completion Plan.
1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;

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2.
3.

 Deferral of Phase 2

SSPPs requesting to defer completion of the service
commitment in order to pursue a degree outside of the
SMART program.

1.

2.

 Degree Level

SSPPs requesting to change their degree level from PhD to MS
or MS to BS when part of a dual degree program.

3.
1.

2.

 Field of Study

SSPPs requesting to change their field of study.

1.

2.

 Full Time Enrollment

SSPPs who request to waive the Full Time Enrollment policy for
one (1) academic term.

1.

2.

 Internship

 Leave of Absence

Statement of support from sponsoring facility,
confirming the need for the change; and
If changing from RC to RT, SF confirms the ability to
accept a MIPR, disburse SMART funds to the
participant, and understands the processes associated
with a RT participant.
Signed personal statement:
a.
Detailing the extenuating circumstances of the
request, including timelines for the deferral
period and confirmation that all other aspects of
the award will not change;
b. Confirming the understanding that transcripts
are due to the SPO and the facility at the close of
each academic term and that a Revised Degree
Completion Plan is due at the start of each
academic year during the deferral; and
c.
Confirmation that you have discussed the need
for the change with the SF;
Statement of support from sponsoring facility
confirming the change will not impact the ability to
hire the participant upon completion of the deferral
period; and
Submit Draft Educational Work Plan.
Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
Statement of support from sponsoring facility,
confirming the need for the change.
Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
Statement of support from sponsoring facility,
confirming the need for the change.
Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change and
confirmation that the request only applies to one
term; and
Attach confirmation on official letterhead from the
academic advisor confirming you will still complete
your degree as awarded if enrollment is decreased.
Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
Statement of support from sponsoring facility,
confirming the internship period is approved to be
waived or alternatively timed.

Waiver Request:
Requests for a waiver are considered for a single internship
period at a time. A waiver of the internship requirement does
not reduce the length of a SSPP’s service commitment.
Alternative Internship Timing:
Requests for an off-cycle internship are considered for a single
internship period at a time.

1.

LOAs that require an absence from school:

1.

Attach confirmation on official letterhead that the
academic institution :
a.
Approves your requested leave of absence and
that the institution will allow you to re-enroll
after the leave is complete (if applicable); and
b. Confirming your degree completion and
conferral dates.

1.

Signed personal statement:
a.
Submit transcripts at the close of each term;
b. Submit the Annual Report each June until the
period of leave is complete; and
Submit a Revised Degree Completion Plan.

2.

1. Personal or family medical
2. Military activation

LOAs that do not require an absence from school:
1. Award Length Change Request denial (if directed)
2. Past 5 year funding cap

 Outside Employment

SSPPs who request to waive the Outside Employment policy.

 Sponsoring Facility

SFs who wish to re-assign a SSPP or SSPPs who lose
sponsorship of their SF for reasons that would not warrant

2.

Signed personal statement detailing the circumstances of
the request, including confirmation that all other aspects of
the award will not change.
1. Signed personal statement detailing the
circumstances of the request, including confirmation

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dismissal.

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that all other aspects of the award will not change.

Cohorts 2008-2011 may request an increase in the stipend rate
for additional qualifications earned in the form of a conferred
STEM degree funded by SMART or by passing qualifying
examinations or equivalent requirements for acceptance as a
permanent Ph.D. candidate.

Cohorts 2008-2011 submit documentation from your
academic institution confirming conferral of STEM degree
funded by SMART or confirmation that by passing qualifying
examinations or equivalent requirements for acceptance as
a permanent Ph.D. candidate.

Cohorts 2012 forward may request an increase in the stipend
rate for additional qualifications earned in the form of a
conferred STEM degree funded by SMART.

Cohorts 2012 forward submit documentation from your
academic institution confirming the conferral of the STEM
degree funded by SMART.

 Withdrawal

SSPPs notify the SMART Program prior to withdrawal.

 Other

SSPPs that have general requests not specifically outlined
above.

Brief statement in Section 3 is requested. No additional
documentation is required.
1. Signed personal statement detailing the
circumstances of the request, including confirmation
that all other aspects of the award will not change;
and
2. Any applicable documentation.

 Stipend Rate Increase

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 1 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, Executive Services Directorate, Directives Division, 4800
Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 OMB Control Number: 0704-0466. 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.

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