NEH Public Scholar Award Acceptance Form

OMB Number 3136-0134 Exp: 7/31/19

You must accept or decline the offer of a 2017-2018 NEH Public Scholar Award no later than Monday, September 18, 2017. To accept the award, please complete, sign, and return the acceptance form to the NEH Public Scholar Program by either scanning and e-mailing it to @emailor faxing it to (202) 606-8204 by this deadline.

1. Application Number: __F_ _Z_ - ___ ___ ___ ___ ___ ___

2. Name: ______________________________________________

3. Social Security Number: ___ ___ ___ - ___ ___ - ___ ____ ____ ___

4. Mailing Address: ___________________________________________

___________________________________________

____________________________________________

Home Phone: ( ) ___ ___ ___ - ___ ___ ___ ___

Office Phone: ( ) ___ ___ ___ - ___ ___ ___ ___

E-mail: _________________________________________

5. Award Period (Note: Tenure automatically begins on the first day of your initial month and ends on the last day of your final month.) Indicate the amount of time you'll be working on your NEH project for each block of time.

From (Month/year): ______ Through (Month/year): ______ o full-time o half-time o other _____

Number of full-time equivalent months covered: ________________________

6. How would you like the stipend paid? Choose only one option.

o Direct deposit payments into your bank account through Automated Clearing House (ACH).

o Direct deposit payments into the account of your employing institution through Automated

Clearing House (ACH).

7. Do you need your first payment early? o No o Yes

8. Do you need a larger first payment? o No o Yes

Additional amount requested: _____________________________________________________

Reason for a larger first payment: __________________________________________________

IMPORTANT: The acceptance form does NOT request banking information for direct deposit of your award payments. Once your completed and signed acceptance form is received by NEH, you will be sent an award letter and a payment schedule that includes instructions for submitting your banking information to NEH.

8. Acceptance and Certification

I accept the offer of a Public Scholar Award and agree to comply with the conditions governing it as set forth in the General Information on NEH Public Scholar Program Awards. I certify that the information submitted in this form is true and correct to the best of my knowledge and that any changes or additions will be promptly reported to NEH.

_________________________________ ______________________________

Signature Date

Paperwork Burden: NEH estimates the average time to complete this form is one hour per response. This estimate includes the time for reviewing the instructions for this form, gathering the necessary data, and entering the data on the form. Please send any comments regarding this estimated completion time or any other aspect of the form, including suggestions for reducing completion time, to the Director, Office of Publications and Public Affairs, National Endowment for the Humanities, Washington, D.C. 20506; and to the Office of Management and Budget, Paperwork Reduction Project (3136-0134), Washington, D.C. 20503. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.