NIFA-09-10 Service Verification

NIFA Veterinary Medicine
Loan Repayment Program (VMLRP)

Service Verification

National Institute of Food and Agriculture
US Department of Agriculture
NIFA-09-10
OMB No. 0524-0047
Form Approved For Use Through: DATE

NIFA Veterinary Medicine Loan Repayment Program
Instructions: Please complete Sections 2 and 3 and return the completed form to NIFA by fax at (202) 720-6486 or
email at [email protected].

Section 1. General Information
VMLRP Participant Name:
Shortage Type:

 Type I: Private Practice (minimum 80% time)
 Type II: Private Practice – Rural Area (minimum 30% time)
 Type III: Public Practice (minimum 49% time)

Shortage Identification Code:
See attached form for more details
Service Period:

01/01/2011 to 03/31/2011

Section 2. Veterinary Service
Instruction: Please review the attached shortage nomination form before answering the following questions.
By checking “Yes”, you are certifying that this participant worked under your supervision during this period, did not
incur leave-without-pay that prevented attainment of the minimum required hours (based on full-time equivalent
of 40 hours per week), and did not terminate employment during this period.
 Yes
 No
By checking “Yes”, you are certifying that the attached shortage nomination form accurately reflects the veterinary
services provided by the participant in the specified area during the specified period.
 Yes
 No

Section 3. Certification
The information shown above is correct. I additionally certify that the participant’s services comply with the applicable Federal,
state and local laws, and is not performing illegal veterinary services for which funding is prohibited by Federal law to the best
of my knowledge. I further certify that the information provided here is accurate to the best of my knowledge. I am aware that
any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.

Supervising Official (Print Name)

Supervising Official (Signature)

Supervising Official’s Phone Number

Supervising Official’s Email Address

Date

Public reporting for collection of information is estimated to average 15 minutes, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
th
reducing this burden to NIFA, OEP, 800 9 St. SW, Washington, DC 20024, Attn: Policy Section.

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NIFA Form 09-10
OMB No. 0524-0047