certification

Faculty Loan Repayment Program (FLRP)

Disadvantaged Background School Certification

Name of Applicant: ___________________________________________

Name of Institution: ___________________________________________

This certifies that the above named individual was determined to be from a disadvantaged background, according to the FLRP definition, while attending this institution. The individual was from an (choose one):

Environmentally Disadvantaged Background (Please provide specifics):

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Economically Disadvantaged Background (Please provide the family size and family income for the year(s), up to the completion of the applicant’s undergraduate studies, based on applicant’s parent’s Federal income tax returns.

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Certifying Official

Name: _______________________________ Date: _____ / _____ / _______

Title: _________________________________________

Phone: _____ - ______ - ________ Fax: _____ - ______ - ________

E-mail: ________________________________________

WARNING: ANY PERSON WHO KNOWINGLY MAKES A FALSE STATEMENT

OR MISREPRESENTATION ON THIS FORM IS SUBJECT TO

PENALTIES WHICH MAY INCLUDE FINES AND IMPRISONMENT

UNDER FEDERAL STATUTE.