Dd Form 2753 - Nsep Service Agreement Report For Scholarship And Fellowship Awards
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2OMB No. 0704-0368
NATIONAL SECURITY EDUCATION PROGRAM (NSEP)
OMB approval expires
SERVICE AGREEMENT REPORT (SAR) FOR SCHOLARSHIP AND FELLOWSHIP AWARDS
The public reporting burden for this collection of information is estimated to average 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. 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,
Alexandria, VA 22350-3100 (0704-0368). Respondents should be aware that notwithstanding any other provision 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.
SEND THIS COMPLETED FORM BY MAIL, FAX, OR EMAIL TO:
Defense Language and National Security Education Office (DLNSEO)
4800 Mark Center Drive, Suite 08F09-2
Arlington, VA 22350
Fax: 703-692-2615
For questions, call or email: (571) 256-0711; nsep@nsep.gov
PRIVACY ACT STATEMENT
AUTHORITY: 50 U.S.C. 1901 et seq., as amended; DoD Directive 1025.02 and 1025.6, National Security Education Program; and E.O. 9397 (SSN),
a s amended.
PRINCIPAL PURPOSE(S): To document recipient's status and compliance in fulfilling the service requirement. The applicable SORN is DHRA 09
located at
ROUTINE USE(S): In the case of a recipient in default of a service agreement, information to include Social Security Number may be disclosed to
consumer reporting agencies; and to other governmental agencies to facilitate collection of amounts owed the government. The DoD Blanket
Routine Uses found at also apply.
DISCLOSURE: Voluntary; however, failure to furnish the requested information may result in NSEP not being able to process your request for service
credit and you may be required to repay the amount of your award, plus interest.
SECTION I - DEMOGRAPHIC DATA
2. FORMER NAME
1. RECIPIENT NAME (Last, First, Middle Initial)
3. SOCIAL SECURITY NUMBER
(Last 4 digits)
4. CURRENT CONTACT INFORMATION
a. STREET AND APARTMENT/SUITE NUMBER
b. CITY
c. STATE
d. ZIP CODE
e. E-MAIL ADDRESS
f. HOME TELEPHONE NUMBER
g. SECONDARY OR WORK TELEPHONE
(Include area code)
NUMBER (Include area code)
5. PERMANENT CONTACT INFORMATION
a. STREET AND APARTMENT/SUITE NUMBER
b. CITY
c. STATE
d. ZIP CODE
e. HOME TELEPHONE NUMBER (Include area code)
SECTION II - RECIPIENT'S STATUS
6. I have been engaged in work in fulfillment of my requirement during this reporting period.
(Complete Items 12 through 20 in Sections III and IV on the back.)
7. I have not graduated from nor terminated enrollment in the degree program pursued while receiving NSEP support.
My anticipated graduation date is (Month/Year)
. (Complete Items 17 and 20 in Section IV.)
8.a. I am furthering my education and request a deferral of the service requirement until I complete my
degree program at
(Institution); my expected graduation date
is (Month/Year)
. (Complete Items 17 and 20 in Section IV.)
b. I am furthering my education and do not request a deferral of the service requirement.
My anticipated graduation date is (Month/Year)
. (Complete Items 17 and 20 in Section IV.)
9. I have not yet obtained employment in fulfillment of my service requirement during this reporting period.
(Complete Items 17 and 20 in Section IV.)
10. I request a one year extension, as the time for completing my service requirement has expired.
(Submit detailed plan outlining how you plan to fulfill your service requirement during the extension period.) (Complete Items 17 and
20 in Section IV.)
11. I request a waiver from my service requirement. (Explain grounds for waiver on a separate piece of paper and attach to SAR.
Please note that waivers are granted only in extreme cases. Also complete Items 17 and 20 in Section IV.)
DD FORM 2753, NOV 2014
PREVIOUS EDITION IS OBSOLETE.
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