3135-0112 National Heritage Fellowships Acceptance form

NATIONAL ENDOWMENT FOR THE ARTS
National Heritage Fellowships Acceptance Form
1. Purpose and Scope: NEA National Heritage Fellowships are awarded by the National Endowment for the
Arts in recognition and support of your significant impact on and your continuing contributions to the
folk and traditional arts.
2. Acceptance: Indicate your acceptance of this fellowship by completing this form and forwarding it to us via
email or fax. (Please make a copy for your own records.)
Field

Information

Legal Name (Last, First, Middle Initial)
Salutation (Dr., Ms., Mr., etc.)
How would you like your name(s) to appear on
the press release? We will share the press
release with you before posting.
Permanent Address (Number and Street)
Permanent Address (City, State, and Zip)
US Citizenship

☐ Yes

☐ No

☐ Yes

☐ No

If Permanent Resident, Visa #
Birthdate
Place of Birth
Native American Alaska Native Tribal Affiliation
(optional and if applicable)
Are you delinquent on the repayment of any
Federal debt? If yes, please attach explanation.

I accept the National Endowment for the Arts’ Individual Fellowship Grant in the amount of $25,000. By
signing below, I certify that the information contained herein is true and correct to the best of my
knowledge, and that I will comply with the Federal requirements specified below.
The Drug-Free Workplace Act of 1988 was enacted on November 18, 1988, as part of Federal omnibus drug legislation. This law
requires applicants for Federal grants to certify that they will not engage in the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance in conducting any grant activity. (For the purposes of this Act, alcohol is not considered
a controlled substance.) Your signature on this form fulfills the certification required of individuals.
A government-wide regulation for implementing the law was published in the Federal Register at 54 FR 4946, on January 31, 1989.
It became effective on March 18, 1989. Therefore, as of that date, the Arts Endowment is not able to award any new grants to
organizations or individuals unless the applicant has provided the required certification.

Field
Signature
Date

Information

Paperwork Reduction Act Statement
The public reporting burden for this collection of information is estimated at an average of 10 minutes 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. We welcome any suggestions that you might have
on improving the guidelines and making them as easy to use as possible. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to:
webmgr@arts.gov, attention: Reporting Burden. Note: Applicants are not required to respond to the collection of
information unless it displays a currently valid U.S. Office of Management and Budget (OMB) control number.
Privacy Act
The following notice is furnished in accordance with the Privacy Act of 1974, 5 U.S.C. 552a:
This information is solicited under the authority of the National Foundation on the Arts and the Humanities Act, 20
U.S.C. 951 et seq. and is used to select persons to participate in the National Endowment for the Arts’ application review
process. Disclosure of this information may be made to members of Congress and to the general public, upon request in
accordance with the Freedom of Information Act (5 U.S. C. 552). Personal biographical data including home address,
home telephone number, and social security number will not be released and is exempt from disclosure under FOIA
exemption (b)(6).
OMB No. 3135-0112 Expires TBD

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