Dependent certification




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DEPENDENT CERTIFICATION

1.  Name of Participant (Mr., Mrs., Ms.) (Last, First, Middle)

          



2.  Activity Title

          



3.   Country of Training

     


 4.  Length of Training (mos.)         

5.  I hereby request that USAID grant permission for the following dependent members of my family to join me during my training program for an estimated length of       months.

6.  Full Name(s) Of Dependents

(Attach supplemental sheet,

if necessary)

Date Of

Birth


Place Of Birth

(city and country)

Nationality

Relationship

          

        

        

        

        

          

        

        

        

        

          

        

        

        

        

          

        

        

        

        

          

        

        

        

        

7.  Source and Amount of Funds Available to Cover My Dependent’s Expenses

          



8.  I understand that the following conditions and regulations will apply if permission is granted for the above-named dependents to join me, and that if I violate any of these conditions, my program may be terminated and USAID may send me a bill of collection to recover the cost of my training event.

 

1.      USAID is not responsible for travel arrangements, hotel reservations, or any other administrative services or support for my dependents.

2.      USAID has no financial responsibility for the travel, medical needs, insurance, or maintenance of my dependents, and I will not receive any additional allowances or additional funds from USAID because of them.

3.      USAID will not continue my maintenance allowance beyond the normal termination date of my program if my normal departure date is delayed on account of my dependents.

4.      My dependents will have no official status and will not accompany me on official visits to training facilities.

5.      I will purchase health insurance for my dependents prior to their departure from their home country. 

6.      I will furnish proof to USAID that my dependents are in good physical health through the completion of the USAID Medical Examination form prior to obtaining approval for my dependents to travel. 

7.     I will be responsible for the cost of round trip international travel for all of my dependents.

8.     I will not permit my dependents to interfere with my program in any way.

9.     I will not permit any of my dependents to apply for or accept any public welfare funds (including public assistance housing or reduced school lunches) in the country of training where I am being trained. 

 





Signature of Participant

 


Date

     





Name of Mission or USAID/W Office Director (or designee)

     


Signature

Date

     





 

 

 

 

 

 

 

 

 



AID 1380-5 (04/2010) Page of


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