Form 002-FLRP

OMB NO. 0915-0150
Expires: 12/31/09

Faculty Loan Repayment Program
Application Checklist
Application and banking information submitted electronically and printing “BCRSIS Receipt of
Submission” deadline – July 7, 2009, 5:00 p.m. ET.
Signed copy of electronic application and “BCRSIS Receipt of Submission” and supporting
documents deadline – July 7, 2009 (postmark date)
You must initial each item on this Checklist, and sign and date the Checklist below. Your signature indicates that you
have read this Bulletin, you understand all items required by the application, and you are certifying the truth and accuracy
of the information submitted. Return the Checklist with your application and supporting documents. Keep a copy
of the application and supporting documents for your records, and submit the original. No application materials
will be returned to applicants.
_____ 1.

Submitted electronic application for the Faculty Loan Repayment Program (FLRP) by
July 7, 2009, 5:00 p.m. ET.

_____ 2.

Copy of printed and signed electronic application.

_____ 3.

Submitted banking information electronically through BCRSIS by July 7, 2009, 5:00 p.m. ET. Go to
HTTPS://NIS.HRSA.GOV/BANKLOGIN.ASPX (insert link) and complete all requested payment
information. Upon completion, print out the “BCRSIS Receipt of Submission” and submit this form with
the rest of your hard copy documentation.
If you are unable to print a copy of the “BCRSIS Receipt of Submission”, please complete the following 2
steps:
1) Contact the HRSA Call Center to log a help-ticket toll-free at 1-800-221-9393 (TTY: 1-877-897-9910),
Monday-Friday (except Federal holidays), 9:00 a.m. to 5:30 p.m. ET; and
2) Complete the Banking Update Form (SF1199A) which may be found at
https://www.fms.treas.gov/eft/1199a/pdf. The completed form must be received or postmarked by July
7, 2009.

_____ 4.

Copy of “BCRSIS Receipt of Submission”.

_____ 5.

Proof of Disadvantaged Background from school official.

_____ 6.

Completed Institution Employment/Loan Repayment Verification Form.

_____ 7.

Copy of employment contract.

_____ 8.

Copy of written agreement with employing institution to provide matching loan repayments (if applicable).

_____ 9.

Letter requesting waiver and documentation of undue financial hardship to support your employing
school’s request for a waiver of its loan repayment obligation (if applicable).

_____ 10.

Completed Loan Information and Verification Forms for each loan for which you are seeking
repayment assistance from the FLRP.

_____ 11.

Copies of original promissory notes or disclosure statements, and statements from current holder
indicating your name, amount borrowed, date of original disbursement, and type of loan.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a current OMB control number. Public reporting burden for this collection is estimated to average 30 minutes per response, including 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 this
burden to HRSA Reports Clearance Office, 5600 Fishers Lane, Room 10-33, Rockville, Maryland 20857.

_____ 12.

Copy of complete loan payment history of previous awarded funds (applicable to past FLRP award
recipients.

_____ 13.

Copies of current account statement showing your loan balance for each loan submitted.

_____ 14.

Signed and dated Faculty Loan Repayment Program Contract.

_____ 15.

Completed Authorization to Release Information.

_____ 16.

Copy of your Curriculum Vitae/Resume.

_____ 17.

Proof of U.S. Citizenship or U.S. National status (e.g., copy of birth certificate, certificate of citizenship,
passport, or naturalization certificate).

_____ 18.

Copy of your health professional degree or certificate, if applicable.

_____ 19.

Letter of good standing from your Program Director if you are in your last year of graduate training or
school with expected date of graduation (if applicable).

_____ 20.

Letter on business letterhead from entity to which existing service obligation is owed (if applicable)
indicating the date the service obligation will be completed.

_____ 21.

Completed Certification Regarding Debarment, Suspension, Disqualification and Related Matters
Form.

_____ 22.

I have read this entire Bulletin and understand that it is my responsibility to submit a complete application.
I understand that my complete application and banking information must be submitted electronically by
July 7, 2009, 5:00 p.m. ET, and the signed copy of my electronic application, “BCRSIS Receipt of
Submission” and supporting documents must be submitted by July 7, 2009 (postmark date). If my
application, banking information and supporting documents are incomplete, I will not be considered for an
FY 2009 FLRP contract award.

_____ 23.

I understand that a FLRP contract award cannot be part of my employment contract.

_____ 24.

I understand that the FLRP contract is not in effect until is it countersigned by the Secretary or his/her
designee.

_____ 25.

Initialed, signed, and dated Checklist.

I certify that the information submitted in this application package is true, complete, and accurate to the
best of my knowledge and belief and does not omit any material fact. I understand that the information
given may be investigated and that any knowing and willful false representation, or concealment, of a
material fact is sufficient cause for rejection of this application, or, if awarded loan repayment, that I am
liable for the return of all awarded funds and, further, that any such false statement or concealment may
be punished as a felony under 18 U.S.C. § 1001 and subject me to civil penalties under the Program Fraud
Civil Remedies Act of 1986.

___________________________________ ________ _________________________________
Applicant Name (print)
Date
Signature of Applicant

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a current OMB control number. Public reporting burden for this collection is estimated to average 30 minutes per response, including 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 this
burden to HRSA Reports Clearance Office, 5600 Fishers Lane, Room 10-33, Rockville, Maryland 20857.