Form 1 Survey

National Institutes of Health Loan Repayment Programs

Complete Final Application 2008

Extramural/ Initial Applicants

OMB: 0925-0361

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0361 can be found here:

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OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click Here to see burden statement

Applicant Information

NIH 2674-1
LRP Tracking Code:

Section 1. Identifying Information
The Loan Repayment Program is a competitive process and the submission of an application does not assure the award of benefits. Only
designated agents of the US Department of Health and Human Services/National Institutes of Health can make commitments for LRP awards.
Applicant's
Name:

Other Names
Used:
(e.g. Maiden)

First

Middle

Last

Suffix

First

Middle

Last

Suffix

Social Security Number:

Note: We collect your Social Security Number [SSN] to verify your
identity, to determine your eligibility for loan repayment assistance
and to keep track of the federal funds you receive. We also use
your SSN for loan repayment and servicing purposes under the
Loan Repayment Program. We also use this information to
determine whether you are eligible for loan repayment and the
amount of that assistance. See Privacy Act information for
additional information.

Section 2. Permanent (Home) Contact Information
Permanent (Home)
Address:

j US n
k
l
m
n
j Non-US
k
l
m

State
City

State

Zip Code

Telephone Number:

(Area code required)

Fax Number:
(optional)

(Area code required)
Email:
(optional)

Instructions: If you do not have a home email
address, please insert your academic or work
email address in this box.

Section 3. Employment (or School) Contact Information
Position Title:

Select Title
Organization:
Division/School:
Department/Section:
j US n
k
l
m
n
j Non-US
k
l
m

Address:
State
City

Telephone Number:

State

Ext:

(Area code required)

Alternate Contact Number:
(optional)

(Area code required)
j Cell
k
l
m
n

j Pager
k
l
m
n

Ext:

Zip Code

Fax Number:

(Area code required)

Email Address:
Please communicate with me at my:

j Permanent (Home) or n
k
l
m
n
j Current (Work or School) Address.
k
l
m

Section 4. Education and Training
Please attach your Biosketch:

Attach File:

Browse...

You can upload a new file to replace any
previous Biosketch you have uploaded
until the form is locked. This form will only
lock when you submit your complete
application.

Important: It is not necessary to have a well-established
career to apply to this program. Please be sure to list
significant honors and grants in your Biosketch.
Click here for instructions on completing your
Biosketch and for a sample Biosketch.
Instructions: Click the "Browse" button and locate your
file. We accept most word processing document types.

Undergraduate Degree:

Year

Degree
Major/Field of Specialization:
Conferring Institution:

Medical/Dental Degree:

Year

NOTE: If MD/Ph.D. complete information for M.D. in this block
and information for Ph.D. separately under "Highest Graduate
Degree."

Degree
Major/Field of Specialization:

Conferring Institution:
Instructions for Medical/Dental Specialty and Subspecialty Training: Select the area(s) in which you have
specialty or subspecialty training and indicate whether you are board eligible or certified in that area.
Specialty:
(optional)

Select a Specialty
Allergy and Immunology
- Clinical and Laboratory Immunology
Anesthesiology
- Pediatrics Anesthesiology
- Critical Care Medicine
- Pain Management
Colon and Rectal Surgery
Board Eligible
j Yes n
k
l
m
n
j No
k
l
m
Board Certified
j Yes n
k
l
m
n
j No
k
l
m
Subspecialty:
(optional)

Highest Graduate Degree (1):

Year

Degree
Major/Field of Specialization:
Conferring Institution:

If Ph.D., please enter a synopsis of your
dissertation abstract here:
(Please limit to 5000 characters, including
spaces - about 1 page)

Graduate Degree (2):

Year

Degree
Major/Field of Specialization:
Conferring Institution:

Graduate Degree (3):

Year

Degree
Major/Field of Specialization:
Conferring Institution:

* Text hidden if Intramural
Section 5. Federal Government Employment
Are you employed for more than 20 hours
per week (5/8 or greater) by a US
Government agency such as the NIH,
CDC, DOD, or the Veteran's
Administration?

Are you currently on a fellowship
supported in whole or in part by a US
Government agency such as the
Veteran's Administration, CDC, or DOD?
Please answer "No" if you are supported

j Yes (Please provide an explanation below) n
k
l
m
n
j No
k
l
m

by a National Research Service Award
(NRSA) Fellowship ( T32/F32 ) through
the NIH.

Section 6. Service Obligation
Note: If you have a service obligation, you may still be eligible for LRP consideration if your service obligation has been or can be deferred for
the entire period of your LRP contract. For assistance, please call the LRP Helpline at 1-866-849-4047. Click here for examples of service
obligations.
Do you owe a service pay-back
obligation?

j Yes (Continue with questions below)
k
l
m
n
j No (Skip to Section 7)
k
l
m
n

Note: Please answer "No" if you have received funding from a
T32/F32 National Research Service Award (NRSA) Fellowship
and list your NRSA Fellowship in Section 2 of the Funding
Information form.

Program Name:
When do you expect to fulfill your
obligation?
Month

Day

Year

Section 7. Voluntary Disclosures
Completion of items in this section is VOLUNTARY. The information provided will be used to measure the extent to which members of these
groups are applying for and receiving NIH Loan Repayment Program contracts and/or for program evaluation. Failure to answer these questions
will have no effect on your consideration for these programs.
How did you learn about the NIH Loan Repayment Programs?
Gender/Race/National Origin/Disability Status
Gender:
Are you Hispanic or Latino?

j Female n
k
l
m
n
j Male
k
l
m
c Yes
d
e
f
g

c No
d
e
f
g

A person of Mexican, Puerto Rican, Cuban, Central or South
America, or other Spanish cultures or origins. This does not
include persons of Portuguese culture or origin.

What is your racial background?:
(Check one or more boxes)

Name of Category
c American Indian or Alaska Native
d
e
f
g
c Asian
d
e
f
g

c Native Hawaiian or Other Pacific Islander
d
e
f
g
c Black, not of Hispanic Origin
d
e
f
g

c White, not of Hispanic Origin
d
e
f
g

Definition of Category
A person having origins in any of the original peoples of North
American, and who maintain cultural identification through
community recognition or tribal affiliation.
A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent
including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.
A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
A person having origins in any of the black racial groups of
Africa. This does not include persons of Mexican, Puerto
Rican, Cuban, Central or South America, or other Spanish
cultures or origins.
A person having origins in any of the original peoples of
Europe, North American, or the Middle East. This does not
include persons of Mexican, Puerto Rican, Cuban, Central or
South America, or other Spanish cultures or origins.

c No Response
d
e
f
g
Disability Status:

Select Disability Code

HANDICAP Definition: The physical or
mental impairment which substantially limits
one or more major life activities; the record
of such impairment; or the perception of
such impairment by others.
Note: In the case of multiple impairments,
the code should indicate the impairment
that results in the most substantial
limitation.

Date of Birth:

Month

Day

Year

Section 8. Certifications
Certification of Nondelinquent Status
The Federal Debt Collection Procedures Act of 1990 precludes a debtor who has a Federal judgment lien against his/her property arising from a Federal
debt from receiving Federal funds until the judgment is paid in full or otherwise satisfied. Applicants for the NIH Loan Repayment Programs must certify that
they do not have a judgment lien against their property arising from a debt to the United States.
I hereby certify that I [ n
j do] [ n
k
l
m
j do not] have a judgment lien against my property arising from a debt to the United States
k
l
m
I hereby certify that I [ n
j am] [ n
k
l
m
j am not] delinquent on any debt to the United States.
k
l
m

Certification of Accuracy of Information Provided
c I certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact
d
e
f
g
that would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information given may be investigated
and that any false representation is sufficient cause for rejection of the application, or, if awarded loan repayment, that I am liable for return of all
awarded funds and, further, that any false statement my be punished as a felony under U.S Code, Title 18, Section 1001. I am aware that any false,
fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program
Fraud Civil Remedies Act of 1986.
I authorize any program to which I owe a service obligation to release information about that obligation to administrators of the NIH Loan Repayment
Program and to other authorized Government officials

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Public reporting for this collection of information is estimated to average 35 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -1
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out
OMB No. 0925-0361
Form Approved for use through xx/xx/xxxx
Click Here to see burden statement

Personal Statement

NIH 2674-2

LRP Tracking Code::

Instructions: (Displayed for NEW APPLICANT ONLY) Use 8,000 characters or less including spaces (approximately two singlespaced, typed pages) to briefly describe your previous research training experience, your short-term academic and research objectives,
your long-term career objectives and your plan to achieve these objectives. Please include your name and the date in the header of the
document.
Instructions: (Displayed for RENEWAL APPLICANT ONLY) Use 8,000 characters or less including spaces (approximately two singlespaced, typed pages) to briefly describe your previous research training experience, your short-term academic and research objectives,
your long-term career objectives and your plan to achieve these objectives. Specify how your research training over the past two years
has helped you realize these goals and what will be achieved in the next year of the program. Please include your name and the date in
the header of the document.
Note: Please know that you can upload a new file to replace any previously uploaded file.
This form will not lock until you submit the complete application.
Upload your
Personal
Statement:

Attach File:

Browse...

Instructions: Click the "Browse"
button and locate your file. We
accept most word processing
formats.

Save and Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 120 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 currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.

NIH Form 2674-2
Privacy Act 09-25-0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out
OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click Here to see burden statement

Recommendations

NIH 2674-3
LRP Tracking Code:

Instructions: Your application requires that you obtain three completed recommendations including one from
your Research Supervisor. Please provide the name and email address for the other individuals who will
provide a recommendation for your application. You may submit up to five names of individuals to ensure that
the mandatory three recommendations are received. Hidden if applicant identified Research Supervisor
Instructions: Your application requires that you obtain three completed recommendations. Please provide
the name and email address for the other individuals who will provide a recommendation for your application.
You may submit up to four names of individuals to ensure that the mandatory three recommendations are
received. Hidden if applicant did not identified Research Supervisor
Recommenders identified in this form will be contacted by email as soon as your press the SUBMIT button and
will be asked to complete an online recommendation form on your behalf. We can only accept
recommendations via the online form. Letters, faxes and other forms of recommendations are not acceptable.
Please ensure that all email addresses are entered accurately as once you press SUBMIT you cannot return to
this form to make changes. If you are looking to find an NIH Email Address, click here.

Section 1 - Required Recommendations
Recommender # 1 - Hidden if applicant identified Research Supervisor
Name:
First

Middle

Last

Suffix

First

Middle

Last

Suffix

Email Address:
In what capacity
do you know the
recommender?
Recommender # 2
Name:

Email Address:
In what capacity

do you know the
recommender?

Recommender # 3
Name:
First

Middle

Last

Suffix

Email Address:
In what capacity
do you know the
recommender?
Section 2 - Optional Recommendations
Instructions: Only three recommendations are required. You may submit up to two additional names to
ensure that at least three recommendations will be received by the NIH on your behalf. All recommenders
identified in this form will be contacted by email as soon as you press the SUBMIT button and will be asked to
complete an online recommendation form on your behalf.
Recommender # 4
Name:
First

Middle

First

Middle

Last

Suffix

Email Address:
In what capacity
do you know the
recommender?

Recommender # 5
Name:

Email Address:
In what capacity
do you know the
recommender?
Section 3 - Release and Waiver
Release to Contact Recommenders

Last

Suffix

g I certify that I am requesting recommendation(s) from individual(s) of my choosing that will be included in
c
d
e
f
my NIH Loan Repayment Program (LRP) application. My application, including the completed
recommendation forms submitted by my recommenders, will be used by NIH officials to determine my
eligibility for participation in an LRP. I understand that the recommendation I am requesting shall be held in
confidence and protected from disclosure by officials of the NIH Loan Repayment Programs according to
Privacy Act System of Records #09-25-0165 (see Confidentiality and Privacy Act Notice). I authorize
administrators of the NIH Loan Repayment Program and other authorized Government officials to contact
the individual(s) I have identified to request any additional information that may be needed in determining
my eligibility for participation in an LRP.

Voluntary Waiver of Future Rights to Access Confidential Recommendations
c By checking this box, I understand that I will not have access to the recommendations based on the
d
e
f
g
promise of confidentiality made to my recommenders in Section 3.
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Public reporting for this collection of information is estimated to average 25 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 is displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA
0925 -0361. Do not return the completed form to this address.

NIH Form 2674 -3
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Logged in as

Log Out

OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click here to see the burden statement

Loan Information

NIH 2674-4
LRP Tracking Code:

Important: The completion of this form requires accurate and comprehensive information. We recommend that you gather your educational loan information
before starting this form. For information on qualifying loans see the Applicant Information Bulletin.
If you have multiple educational loans you will need to complete a separate form for each loan type or lender. For example: if you have 5 loans under the same lender
that are the same loan type, then you will need to complete one form for all 5 loans. If all of your loans have been consolidated into one loan account, you need only
submit one Loan Information form. For more information on completing this form click here . The information you provide in this form will be sent to the lending institution
for the purposes of verifying the loan type, balance, payment amount, principal and interest, loan purpose, and repayment status, including deferment, grace, and
forbearance status.
If your application is approved you will be asked to fax us both the Promissory Note/Disclosure Document AND a current Account Statement (dated within 90 days) for
each loan. For information on these documents, click here .
Section 1 - Loan Information
Loan Account
Number:
Instructions: Please select your lender from the list below. If your lender is not included in the list, please select "Other" and fill in the necessary
information. You may also edit the address information that appears for the lenders.
Name of Lending
Institution/Servicing
Agent:

Select Lender

Other:

Address:

State

City

State

Zip Code

Name of servicing
agent of the loan to
whom payments are
sent (if different):
Address:

State
City

State

Zip Code

Section 2 - Loan Details
Original Amount of
Loan:

Date When Loan was
Disbursed:

Month

Monthly Payment
Amount:
Payoff Balance:

Day

Year

NOTE: If your loan is in deferment or forbearance, please
enter $1.00 in the monthly payment field.

Payoff valid through
what date?

Month
Current Interest Rate

Day

Year

of Loan:
Interest Type:
Is this loan
consolidated with a
spouse or another
individual?

%
Select Interest Type
NOTE: Loan consolidations that include the underlying loans of
spouses or other individuals are ineligible for repayment consideration.

j Yes
k
l
m
n
j No
k
l
m
n

Loan details accurate
as of what date?

Month

Day

Year

Section 3 - Loan Deferment Information
i Repayment (If selected, please proceed to next section)
j
k
l
m
n
j Forbearance
k
l
m
n
j Deferment/Grace
k
l
m
n

If you are not currently repaying your loans, please identify the start and end dates of the current postponement period:
Start date of current
period:

Month

Day

Year

Month

Day

Year

End date of current
period:

Interest Bearing?

j Yes
k
l
m
n
j No
k
l
m
n

Section 4 - Loan Repayment Information
Are you currently
repaying the loan?

Are your payments up
to date?

If this is a
consolidated loan,
were the underlying
loans ever past due
or delinquent,
incurring late fees,
penalty fees or
collection costs?

j Yes
k
l
m
n
j No
k
l
m
n

Note: Delinquent loans, loans in default, loans not current in their payment schedule,
loans already repaid or loans with promissory notes that have been signed after the
LRP effective date are not eligible for repayment. Late Fees, penalty fees, additional
interest charges or collection costs will not be repaid by the LRP.

j Yes (or Not Applicable)
k
l
m
n
j No
k
l
m
n

j Yes
k
l
m
n
j No (or Not Applicable)
k
l
m
n

Date Loan
Repayment Started:

Month

Day

Year

Purpose of Loan:
Type of Loan:

Select Type of Loan

Other:

Section 5 - Certification by Applicant/Borrower
c I hereby apply to enter into an agreement with the Secretary of HHS for repayment of the educational loan listed above, incurred solely for the costs of education,
d
e
f
g
including reasonable living expenses. I hereby certify that the information given in this application is true, complete, and accurate to the best of my knowledge and

does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of the omission. I am aware that any false, fraudulent, or
fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.
I hereby authorize the lending institution, servicing agent, and/or institutional program named above to release information about my loan or any loan owned, serviced,
or administered by my lending institution, servicing agent, or program administrator to the administrators of the NIH Loan Repayment Programs (LRP), and to other
authorized Government officials. This authorization shall remain in effect during my application and participation in the NIH LRP and 120 days after completion of LRP
contracted service.

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Public reporting for this collection of information is estimated to average 75 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 currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -4
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out
OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx

IC Recommendation for LRP Funding

NIH 2674-5
LRP Tracking Code:

Applicant's Identifying Information
Applicant Name:
Social Security
Number:
Type of LRP:
Contract length (to
commence on
program eligibility
date):
Position Information
Title Select Title

Other:

Pay Select Pay Plan
Plan/Occupational
Series:
Grade (if
appropriate):
NIH Salary at
Program Eligibility
Date:

Note: Please provide the applicant's basic NIH salary as of the
applicant's program eligibility date*. For applicants employed
under the Commissioned Corps, salary comprises base pay plus
quarters, subsistence, and variable housing allowances. Special
and bonus pay, such as board-certified, contract, and variable
incentive pay, are not included. Similarly, for applicants under the
General Schedule pay plan, Physicians Comparability
Allowances (PCA) are not included in the salary calculation.
However, pursuant to 5 CFR § 595.105(e), an individual receiving
a PCA who is accepted into the LRP must have his/her PCA
reduced by the amount of the loan repayment upon entry to the
LRP.
* The program eligibility date is the receipt date of an application
in the Office of Loan Repayment or the EOD date for new hires,
whichever occurs later.

Personnel Select One
Documentation

Type of Assignment:

j Permanent
k
l
m
n
j Temporary
k
l
m
n

Start Date of
Assignment from
SF52/SF50: Month Day Year

Note: The applicant's NIH Salary needs to be supported by faxing
this documentation to the NIH Office of Loan Repayment and
Scholarship at 1-866-849-4046. Please use the Fax Coversheet
that is provided when you click "Submit" on this form to submit
the required documentation.

End Date of
Assignment from
SF52/SF50: Month Day Year
Can the assignment
be extended?

j Yes (or N/A)
k
l
m
n
j No
k
l
m
n

Instructions: After printing this application,
please coordinate the clearance process by
obtaining the necessary signatures.
Incomplete applications will be returned to the
LRPC. Completed applications from LRPC's
in support of renewal and new applicants are
due March 1 and June 1, respectively. If you
have any questions about completing this
form, please call the Loan Repayment
Program at 1-866-849-4047.
NIH Form 2674 -5
Privacy Act 09 -25 -0165

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OMB No. 0925 -0361
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Research Activities

Click Here to see burden statement

NIH 2674-6
LRP Tracking Code:

Instructions: Identify your Principal Investigator or Research Supervisor below. Your Principal
Investigator/Research Supervisor will be asked to complete a recommendation form on your behalf, to concur
with your research project description and to provide additional information on your research training and
laboratory environment.
Note: Your Principal Investigator/Research Supervisor will NOT have access to complete their online forms
until you submit this form. Click here to see the information they are being asked to provide.
When you press submit this form will lock and an email will be sent to your Principal Investigator/Research
Supervisor to request that (s)he complete the online forms.
Name and email
address of your
Principal Investigator
or Research
Supervisor:

First Name

Last Name

Email Address

In what capacity do
you know your
Principal
Investigator?
Section 1 - Research Activities
Instructions: Use 20,000 characters or less including spaces (approximately six single-spaced, typed pages)
to describe the research activities you will pursue over the next two years and your specific responsibilities and
role in the research project(s). Also briefly describe the overall research environment, including intellectual
and physical resources available to you. Literature citations are included in the character count and should be
listed on the last page. Please include your name, employer, title of your research project and the date in the
header of the document.
Research Project
Title:

(Please limit your response to 256 characters or less.)

Shortened/General
Title:

Instructions: Enter
a short title that
summarizes your
research.
(Please limit your response to 81 characters or less.)

Please attach your

Attach File

Instructions: Click

research activities
description:

File

Browse...

the "Browse" button
and locate your file.
We accept most
word processing
formats.

Section 2 - Research Environment - Section Displayed for INDEPENDENT RESEARCHER ONLY
Instructions: Use 5,000 characters or less (approximately one typed page) to describe the current research
conducted in the branch/laboratory/section/department where the applicant is located and the availability of
appropriate scientific colleagues, institutional research, and facilities.
Please attach a file
describing the
research environment:

Attach
File

Browse...

Instructions: Click
the "Browse" button
and locate your file.
We accept most
word processing
formats.

Section 3 - Career Development Plan - Section Displayed for INDEPENDENT RESEARCHER ONLY
Instructions: Use 5,000 characters or less (approximately one typed page) to describe your career
development plan and explain how this plan will foster the development of your career in research. Specify the
types of research methods and scientific techniques to be learned, membership in journal clubs or groups and
conferences and seminars to be attended.
Please attach a file
describing your career
development plan:

Attach
File

Browse...

Instructions: Click
the "Browse" button
and locate your file.
We accept most
word processing
formats.

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Submit

Public reporting for this collection of information is estimated to average 180 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
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to NIH, Project Clearances Office, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, Attention: PRA 0925-0361. Do not return the completed form to this address.

NIH 2674-6
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

LogOut
OMB No. 0925 -0361
Form approved for use through xx/xx/xxxx
Click Here to see burden statement

Assessment of Research Activity

NIH 2674- 7
LRP Tracking Code:

Basic Information (Section hidden if information is already complete)
To access the LRP application system, please provide the following information. After you click "Save and Continue" the next form will appear on
your screen for completion.:
Your Name:
First

Middle

Last

Suffix

Position/Title:
Organization:
Division/School:
Department/Section:
Address:

j US n
k
l
m
n
j NonUS
k
l
m

State

City

Telephone Number:

State

Zip Code

(including area code)

Ext:

(Area code required)

Fax Number:
(including area code)

(Area code required)

Save and Continue
Privacy Act 09 -25 -0165

Applicant Identifying Information
Applicant's Name:
Organization:
Section 1 - Concur with Applicant's Research Project Description
Instructions: The applicant has provided the statement linked below describing his/her research project. Please review this statement and indicate your
concurrence by checking the box below. You may submit a revised file by uploading a new document. Caution: If you upload a new file, that file will replace the
document the applicant uploaded. Please note that the length is limited to 20,000 characters or less including spaces (approximately five single-spaced typed
pages plus one page for references).
Research Project Title:

Review Statement:
Click here to view applicant's statement
Principal Investigator/Research
Supervisor Concurrence:
Upload New Research Project, if
necessary:

c I concur with this statement.
d
e
f
g
Browse...

Attach File:

Instructions: Click the "Browse" button and
locate your file. We accept most file types.

Section 2 - Description of Applicant's Research Environment
Instructions: Use 5,000 characters or less (approximately one typed page) to describe the current research conducted in the
branch/laboratory/section/department of the applicant and the availability of appropriate scientific colleagues, institutional research, and facilities.
Please attach a file describing the
research environment:

Browse...

Attach File:

Section 3 - Applicant's Research Training/Mentoring/Career Development Plan
Instructions: Use 5,000 characters or less (approximately one typed page) to detail the applicant's research training program and mentoring plan. Specify the
types of training interactions the applicant will have with you, what training mechanisms will be used, what research methods and scientific techniques will be
learned, what journal clubs or groups the applicant will join, and what conferences and seminars the applicant will attend. If another laboratory staff member will
be involved in the mentoring program, please provide his/her name and describe his/her degree of involvement.
Please attach a file describing the
applicant's research
training/mentoring/career
development plan:

Attach File:

Browse...

If another laboratory staff member
will be involved in the mentoring
program, please provide his/her
Biosketch:

Attach File:

Browse...

Section 4 - Biosketch of Principal Investigator/Research Supervisor

Click here for instructions on completing a
Biosketch and for a sample Biosketch in PDF
or Rich Text Format (rtf).

Please submit your Biosketch:

Attach File:

Browse...

Click here for instructions on completing a
Biosketch and for a sample Biosketch in PDF
or Rich Text Format (rtf).

Section 5 - Principal Investigator/Research Supervisor Assurance
g I certify that (1) the statements herein are true, complete, and accurate to the best of my knowledge; (2) I agree to accept responsibility for the scientific
c
d
e
f
conduct of the research project; (3) I certify that the applicant, named in Section 1 of this form, will be provided the necessary time and resources to engage
in the named research project if a Loan Repayment contract is awarded and (4) I also agree to provide periodic (usually quarterly) service verifications on
behalf of this applicant if a Loan Repayment contract is awarded. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to
criminal, civil, or administrative penalties.

Save & Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 30 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 is displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -7
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out
Form Approved for use through xx/xx/xxxx
OMB No. 0925 -0361
Click here to see burden statement

Research Accomplishments

NIH 2674-8
LRP Tracking Code:

Instructions: Please use 5000 characters or less including spaces (approximately one typed page), to describe your research accomplishments during
the current LRP contract period.
Paragraph Displayed for INTRAMURAL RESEARCHER ONLY: In addition, you are required to submit documents which reflect your research
accomplishments. This requirement may be satisfied by faxing one copy of three representative publications, which can include abstracts, to 866-8494046. Submitting this form will generate a fax cover sheet which you can print and use for this purpose.

Paragraph Displayed if the applicant identified Research Supervisor: Note: Your Principal Investigator/Research Supervisor will be asked to
concur with your statement and to provide their assessment of your research accomplishments. Since your Principal Investigator/Research Supervisor
will NOT have access to complete their online forms until you submit this form.
c Click here if you have recently moved to a new laboratory and a different individual (not your current Research Supervisor) can better concur with
d
e
f
g
and assess your research accomplishments.

*Text hidden if box is not checked.
Please provide the name and email address of the
Research Supervisor who can best concur and assess
your research accomplishments over the past two years.

Please attach your description of your
research accomplishments:

Attach File:

First Name

Last Name

Browse...

EmailAddress

Instructions: Click the "Browse" button and locate
your file. We accept most word processing
formats.

Save and Continue Later

Submit Form and Print Fax Cover

Public reporting for this collection of information is estimated to average 70 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH 2674-8
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out
OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click Here to see burden statement

Certifications
for Online
Applications

NIH 2674-9
LRP Tracking Code:

Instructions please print, sign and fax this form without a cover page to 866-849-4046.
Continue

Section 1 - Certification by Applicant/Borrower
I hereby apply to enter into an agreement with the Secretary of HHS for repayment of the educational loan
listed in my application, incurred solely for the costs of education, including reasonable living expenses. I
hereby certify that the information given in this application is true, complete, and accurate to the best of my
knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent as
a result of the omission. I am aware that any false, fraudulent, or fictitious statement may, in addition to other
remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies
Act of 1986. I hereby authorize the lending institution, servicing agent, and/or institutional program named in
my application to release information about my loan or any loan owned, serviced, or administered by my
lending institution, servicing agent, or program administrator to the administrators of the NIH Loan Repayment
Programs (LRP) and other authorized Government officials. This authorization shall remain in effect during my
application and participation in the NIH LRP and 120 days after completion of LRP contracted service.
____________________________________________________
Signature (sign your full name in ink)

_____________________
Date

Section 2 - Applicant's Certification of Accuracy of Information Provided
I certify that the information given in this application is true, complete, and accurate to the best of my
knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent as
a result of the omission. I understand that the information given may be investigated and that any false
representation is sufficient cause for rejection of this application, or, if awarded loan repayment, that I am liable
for return of all awarded funds and, further, that any false statement may be punished as a felony under 18
U.S.C. § 1001. I am aware that any false, fraudulent, or fictitious statement may, in addition to other remedies
available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of
1986. I authorize any program to which I owe a service obligation to release information about that obligation
to administrators of the NIH Loan Repayment Program and other authorized Government officials. I further
certify that the named research project complies with applicable Federal, state and local laws (e.g., applicable
human subject protection regulations) and is not research for which funding is prohibited by Federal law
____________________________________________________
Signature (sign your full name in ink)

_____________________
Date

Section 3 - Applicant's Request for Confidential Recommendations
I certify that I am requesting recommendation(s) from individual(s) of my choosing that will be included in my
NIH Loan Repayment Program (LRP) application. My application, including the completed recommendation
forms submitted by my recommenders, will be used by NIH officials to determine my eligibility for participation
in an LRP. I understand that the recommendation(s) I am requesting shall be held in confidence and protected
from disclosure by officials of the NIH Loan Repayment Programs according to Privacy Act System of Records
#09-25-0165 (see Confidentiality and Privacy Act Notice in this application package). I authorize administrators
of the NIH Loan Repayment Program and other authorized Government officials to contact the individual(s) I
have identified to request any additional information that may be needed in determining my eligibility for
participation in an LRP.
____________________________________________________

_____________________

Signature (sign your full name in ink)

Date
Continue

Public reporting for this collection of information is estimated to average 20 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 currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA
0925 -0361. Do not return the completed form to this address.
NIH 2674-9
Privacy Act 09 -25 -0165

Logged in as

Log Out

OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click here to see the burden statement

Institutional Contact

NIH 2674-10
LRP Tracking Code:

Instructions: To verify institutional support for your research, please provide contact information for the official at the institution where you are
conducting your research who can provide verification of compensation amounts and availability of time and resources to conduct your proposed
research. Institutional Officials identified in this form will be contacted by email as soon as you press the SUBMIT button and will be asked to
complete an online form on your behalf that will include an assurance of two years of continuing support and a minimum 50% commitment (20 hours
per week) of research effort. Please ensure that all email addresses are entered accurately as once you press SUBMIT you cannot return to this form
to make changes.
Important: The official providing this information should be someone authorized to reply for the organization. Common titles for this individual are
dean, associate dean, provost or chancellor of research & sponsored programs, or vice president of research administration. If you are not certain
whom to name, please consult with your research supervisor or principal investigator.
Note: Several Institutions have provided us with the proper contact for this certification. You may use the list below to check for your institution. If you
select one of the organizations from the list, the system will automatically update the contact information for you. You will be allowed to change the
information, if needed. If you do not see your institution listed, please enter the Name and Email address of your contact.
Contact Information for the Institutional Representative
Organization:
Name:
First

Middle

Last

Suffix

Email Address:
Save and Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 5 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.

NIH 2674-10
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out

Disadvantaged Background Documentation

OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click Here to see burden statement

NIH 2674-11
LRP Tracking Code:

An individual from a disadvantaged background (42 CFR pt. 57.1804(c)) is one who comes from a
family with an annual income below low-income thresholds according to family size as published by
the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and
adjusted by the Secretary for use in all health professions programs. The Secretary periodically
publishes these income levels in the Federal Register. Note that the published levels represent the
low-income levels for the period from the year of publication to the present. If you are establishing
your eligibility based on a prior year, the published levels for that year will apply. Current financial
need alone is NOT sufficient to classify an individual as being from a disadvantaged background.
Instructions for Applicant
Please indicate how you qualify for the Clinical Research LRP for Individuals from Disadvantaged
Backgrounds (Intramural or Extramural). Do not complete this form if you are not applying for the Clinical
Research LRP for Individuals from Disadvantaged Backgrounds.

(1) f
g I have received a loan from the Health Professions Student Loans
c
d
e
(HPSL) or Loans for Disadvantaged Student Program.

(2) g
c I have received a scholarship from the U.S. Department of Health and
d
e
f
Human Services under the Scholarship for Individuals with
Exceptional Financial Need.

(3) f
g I have a written statement from my former health professions school
c
d
e
(s) that I qualified for Federal disadvantaged assistance during
attendance at the school.

Important: You must submit this documentation to the NIH Office of Loan Repayment
Programs by FAX at 866-849-4046. Your application cannot be considered without this
documentation.
Save and Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 45 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 currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA
0925 -0361. Do not return the completed form to this address.

NIH Form 2674 -11
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

OMB No. 0925-0361
Form approved for use through xx/xx/xxxx

134435
U.S. Department of Health and Human Services
National Institutes of Health

NIH Loan Repayment Program Contract
Sections 487A, 487B, 487C, 487E, and 487F of the Public Health
Service Act (“Act”) authorize the Secretary of the Department of Health
and Human Services (“Secretary”), and Section 485G authorizes the
Director, National Center on Minority Health and Health Disparities
(NCMHD), to enter into contracts with qualified health professionals
under which such professionals agree to conduct research in
consideration of the Federal government agreeing to repay, for each year
of such service, not more than $35,000 of the principal and interest of the
educational loans of such professionals. In return for these loan
repayments, applicants must agree to participate in qualifying research,
for an initial period of obligated service of not less than two years (or a
minimum of three years for General Research Loan Repayment Program
participants), as one of the following: an NIH employee or a health
professional engaged in qualifying research at an institution determined
by NIH to be eligible to sponsor individuals who engage in qualifying
research.
Applicants are required to submit a signed contract which includes the
Terms and Conditions of participation in the LRP with their applications.
The Secretary/NCMHD Director shall execute only those contracts
submitted by applicants who are selected for participation.

The Terms and Conditions for participating in the LRP follow:

Section A - Obligations of the Secretary or NCMHD Director
Subject to the availability of funds appropriated by the U.S. Congress for
the NIH and/or the LRP, the Secretary/NCMHD Director agrees to:
1. Pay, in the amount provided in Paragraph 2 of this section, the
undersigned applicant’s qualifying educational loans. Qualifying health
professionals’ loans consist of the principal, interest, and related
expenses (such as the required interest premium on the unpaid balances
of some loans) of qualified Government (Federal, State, and local) and
commercial loans obtained by the applicant for the following expenses:

b. for the first, second, and third year of qualified service, otherwise
qualified applicants for the Intramural General Research LRP, who are
participating in ACGME accredited clinical training programs, payment of
repayable debt will be no more than $15,000 per year;
c. one- or two-year continuation renewal contracts, beyond the second
year (or third year, for contracts under the General Research LRP), may
be competitively offered;
d. if the applicant’s contract is renewed, the NIH will repay at the rate of
50% of the remaining repayable debt for each year of contract renewal,
up to the $35,000 annual maximum (the repayable debt amount is
calculated annually); or 100% of the repayable debt if the annual
disbursement is $5,000 or less; and
e. payments are to be made on a delayed quarterly schedule after
completion of qualified research, unless otherwise agreed to by the
Secretary/NCMHD Director and the participant.
3. Provide reimbursement for increased Federal tax liability resulting from
payments made pursuant to Paragraph 1 of this section in an amount
equal to 39% of the total amount of loan repayments made for each tax
year in which such payments were made.
4. Payment of qualifying educational loans will be made directly to the
lender(s). If there is more than one outstanding qualifying educational loan,
the Secretary/NCMHD Director will repay the loans in the following order,
unless the Secretary/NCMHD Director determines significant savings
would result from paying loans in a different order of priority: (a) HEAL; (b)
Other loans issued or guaranteed by the Federal Government; and (c)
Other loans.
5. Once a loan repayment contract has been signed by both parties, the
Secretary/NCMHD Director shall obligate such funds as will be necessary
to ensure that sufficient funds will be available to make loan repayments
and tax reimbursements to cover the repayable debt, as defined in
Paragraph 2 of this section.

Section B - Obligations of the Participant

a. undergraduate, graduate, and health professional school tuition
expenses;

The participant agrees to:

b. other reasonable educational expenses required by the school(s)
attended, including fees, books, supplies, educational equipment and
materials, and laboratory expenses; and

1. Provide a description of each of his or her outstanding qualified
educational loans and supporting documents, in a form and manner as
defined by the Secretary/NCMHD Director;

c. the cost of room and board, and other reasonable living expenses as
determined by the Secretary/NCMHD Director.

2. Serve his or her 2- or 3-year minimum period of research service, which
commences on the program eligibility date, by conducting qualifying
research, as one of the following: an NIH employee or a health
professional engaged in qualifying research at an institution determined by
NIH to be eligible to sponsor individuals who engage in qualifying research;

2. An applicant must have qualifying educational loans equal to or in
excess of 20% of his or her annual NIH base salary (Intramural) or
institutional base salary (Extramural) on his or her program eligibility
date. This amount is the “ debt threshold.” Annual income or
compensation refers to “ institutional base salary,” which is the annual
amount the institution pays for the applicant’s appointment, whether the
time is spent in research, teaching, patient care, or other activities.
Institutional base salary excludes any income that an applicant may earn
unrelated to the duties for the institution. The “ program eligibility date” is
the date on which his or her contract is executed by the
Secretary/NCMHD Director and he or she is engaged in qualifying
research. An amount equal to 50% of the debt threshold will not be
repaid by the NIH, and must be repaid by the participant to his or her
lender(s) (“ participant obligation”). NIH will repay the remaining
educational debt (“ repayable debt”) as follows:
a. at the rate of one-fourth of the repayable debt for each year of
qualified service up to a $35,000 annual maximum;

NIH 2674-12 (Page 1 of 2)
Revised 11-03 Printed xx/x/xxxx

3. Provide written verification of the lender’s crediting of all LRP
payments and resulting account balances within a reasonable time after
such payments are credited;
4. Repay the NIH for any sums paid erroneously to his or her lender(s),
repay the NIH for any sums advanced to his or her lenders prior to
satisfying his or her research service, and assist the NIH in obtaining a
refund from his or her lender(s) for such sums;
5. Make payments to lenders on their own behalf for periods of Leave
Without Pay (LWOP); and
6. Comply with the provisions of Title 42, U.S. Code of Federal
Regulations, Part 68a, Part 68c, and other policies or regulations
governing the NIH Loan Repayment Programs, as applicable.

Privacy Act 09-25-0165

134435
Section C - Breach of Written Loan Repayment Contract
1. In accordance with 42 USC 254o, which addresses enforcement of the
National Health Service Corps LRP and will be regarded as equally
applicable to the NIH’s LRPs, any participant who fails to complete the
minimum 2- year (or 3-year for General Research LRP) research service
obligation required under the initial contract will be considered to have
breached the contract and will be subject to assessment of monetary
damages and penalties as specified in Paragraph 3 below.
a. Loan Repayment Program participants who are serving as NIH
employees, and who are terminated for cause or for the convenience of
the Government will not be considered to have committed a breach of
contract, and monetary damages and penalties will not be assessed.
b. Occasionally, a participant’s assignment may evolve and change so
that a determination is reached that he/she is no longer engaged in
qualified research. Similarly, the research needs and priorities of the
NIH or the sponsoring institution may change, so that a determination
is made that the researcher’s skills may be better utilized in a research
assignment which does not qualify for the LRP. Under these
circumstances, the following will apply:
1) Since no authority exists for the Secretary/NCMHD Director to
make repayments on behalf of health professionals who are not
engaged in qualified research, loan repayments will cease as of the
date such determination is made.
2) Normally, job changes of this nature will not be considered a
breach of contract on the part of either the Secretary/NCMHD
Director or the Loan Repayment Program participant. Based upon
the recommendation of the Secretary/NCMHD Director, the Loan
Repayment Program participant will be released from the remainder
of his/her service obligation without assessment of damages or
monetary penalties. Loan Repayment Program participants will be
permitted to retain the benefit of all loan repayments made or owed
by the NIH on their behalf up to the date of the contract release,
except any payments advanced beyond the period of service
rendered. Any payments advanced prior to research service must be
repaid to the Government.
2. Loan Repayment Program participants who sign a continuation
contract for a third, fourth, or subsequent year, and who fail to
complete the period specified, will not be subject to monetary
damages or penalties. However, any payments advanced beyond
the period of research service rendered must be repaid to the
Government, pursuant to Section B, Paragraph 4.

OMB No. 0925-0361
Form approved for use through 6/30/2008
3. Penalties for Failing to Complete the Service Obligation - In

accordance with the statute, the Secretary/NCMHD Director will recover
the following from participants who fail to complete the minimum service
obligation:
a. If the applicant, for any reason, fails to complete the two-year
period of obligated service (three-year period for General Research
LRP), he or she shall be liable to the United States for an amount
equal to the sum of:
1)
the total of the amounts paid by the United States to, or on
behalf of, the applicant under Paragraphs 1, 2 and 3 of
Section A of this Contract for any period of obligated service
not served;
2) an amount equal to the product of the number of months of
obligated service not completed by the applicant, multiplied by
$7,500; and
3) interest on the amounts described in (a) and (b) of this
paragraph at the maximum prevailing rate, as determined by
the Treasurer of the United States, from the date of the
breach; except that the amount the United States is entitled to
recover shall not be less than $31,000.
b. Any amount the United States is entitled to recover shall be paid
within 1 year of the date the Secretary/NCMHD Director
determines that the applicant is in breach of this written Contract.
c. Any obligation of the participant for payment of damages may be
released by a discharge in bankruptcy under Title 11 of the United
States Code only if such discharge is granted after the expiration of
the 7-year period beginning on the first date that payment of such
damages is required, and only if the bankruptcy court finds that
nondischarge of the obligation would be unconscionable.

Section D - Cancellation, Suspension, and Waiver of
Obligation
1. Any service or payment obligation incurred by the participant under
this
contract will be canceled upon the participant’s death.
2. The Secretary/NCMHD Director may waive or suspend the participant’
s service or payment obligation incurred under this contract if:
a.
compliance by the participant with the Terms and Conditions of
this contract is impossible or would involve extreme hardship,
b.
and enforcement of such obligation would be unconscionable.

Section E - Contract Termination
1. The Secretary/NCMHD Director may terminate this Contract if, not
later than 45 days before the end of the fiscal year in which the Contract
was entered into, the individual:
a.
submits a written request for such termination; and
b.
repays all amounts paid on behalf of the individual under
Paragraphs 1, 2 and 3 of Section A of this Contract.

The Secretary/NCMHD Director or his/her authorized representative must sign this contract before it becomes
effective
Applicant's Name

Applicant's Signature

Date

Secretary of Health and Human Services/NCMHD Director or Designee

Contract Period(s)
First
From:
Second From:

To:
To:

Date

Initial Contract ___

Renewal Contract ___

Public reporting for this collection of information is estimated to average 20 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to NIH, Project Clearance Office, 6701 Rockledge Drive, MSC 7730, Bethesda, MD 20892-7730, Attention: PRA
(0925-0361). Do not return the completed form to this address.

NIH 2674-12 (Page 2 of 2)
Revised 11-03 Printed xx/x/2007

Privacy Act 09-25-0165

Log Out
OMB No. 0925 -0361
Form approved for use through xx/xx/xxxx
Click here to see burden statement

Recommendation

NIH 2674-13
LRP Tracking Code:

Basic Information (Section hidden if information is already complete)
To access the LRP application system, please provide the following information. After you click "Save and Continue" the next form will
appear on your screen for completion.:
Your Name:
First

Middle

Last

Suffix

Position/Title:
Organization:
Division/School:
Department/Section:
Address:

j US n
k
l
m
n
j NonUS
k
l
m

State

City

Telephone Number:
(including area code)

State

(Area code required)

Ext:

Zip Code

Fax Number:
(including area code)

(Area code required)

Save and Continue
Privacy Act 09 -25 -0165

Important: Please note that the applicant did not waive future access to this information. Therefore, the information you provide cannot be protected
from disclosure.
Important: Please note that the applicant waived future access to this information. Therefore, the information you provide shall be held in confidence
and waived if protected from disclosure by officials of the NIH Loan Repayment Programs according to Privacy Act System of Records #0925-0165.
Section 1 - Applicant Information
Name:
Applicant's Organization:
Loan Repayment Program (LRP) Applied
For:

Clinical Research LRP

Section 2 - Recommendation
Instructions: All fields on this form are required and all text fields have size limits. You may elect to cut and paste text from another
document into the text fields.
If you have no further information to add to a question, please indicate "No Comment" or "N/A".
Relationship to Applicant
In what capacity do you know the
applicant?
(Please limit your response to 100 characters or less.)

How long have you known the applicant?
(Please limit your response to 50 characters or less.)

Select the rating that best indicates your assessment of the applicant in relation to his/her peers.

Rating of Applicant

Previous training and experience to
prepare for a [clinical research] career:
*Text varies based on LRP

(Outstanding) n
j1 n
k
l
m
j2n
k
l
m
j3n
k
l
m
j4 n
k
l
m
j5n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m

Career goals and plans to achieve these
goals:

(Outstanding) n
j1 n
k
l
m
j2n
k
l
m
j3n
k
l
m
j4 n
k
l
m
j5n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m

Commitment to a career in [clinical
research:]

(Outstanding) n
j1 n
k
l
m
j2n
k
l
m
j3n
k
l
m
j4 n
k
l
m
j5n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m

Potential for a career in [clinical research:]

(Outstanding) n
j1 n
k
l
m
j2n
k
l
m
j3n
k
l
m
j4 n
k
l
m
j5n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m

Likelihood to become an independent
researcher:

(Outstanding) n
j1 n
k
l
m
j2n
k
l
m
j3n
k
l
m
j4 n
k
l
m
j5n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m

Potential for success in research or
academic medicine:

(Outstanding) n
j1 n
k
l
m
j2n
k
l
m
j3n
k
l
m
j4 n
k
l
m
j5n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m

Overall Assessment of Applicant
What are the main strengths and
weaknesses that the applicant brings to
his/her research environment?

(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

*Text hidden if 'Renewal'
What are the weaknesses that
might limit the applicant's
effectiveness in conducting
research (basic science or
pediatric research)?

*Text hidden if 'New'

(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

Assess the applicant's
accomplishments over the
past two years and what
advantages will be conferred
by an additional year of
continued research
experience?

(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

What is your overall recommendation for
the applicant?

(High) n
j1n
k
l
m
j2n
k
l
m
j3 n
k
l
m
j4n
k
l
m
j5 n
k
l
m
j6n
k
l
m
j 7 (Do Not Recommend)
k
l
m

(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

Section 3 - Recommenders Certification
c I certify that the statements herein are true, accurate and complete.
d
e
f
g
Save and Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 20 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 is displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this
address.
NIH Form 2674 -13
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

Log Out
OMB No. 0925 -0361
Form approved for use through xx/xx/xxxx
Click Here to see burden statement

Assessment of Research Accomplishments

NIH 2674-14
LRP Tracking Code:

Basic Information (Section hidden if information is already complete)
To access the LRP application system, please provide the following information. After you click "Save and Continue" the next form will
appear on your screen for completion.:
Your Name:
First

Middle

Position/Title:
Organization:
Division/School:
Department/Section:
Address:

j US n
k
l
m
n
j NonUS
k
l
m

State

Last

Suffix

City

Telephone Number:
(including area code)

State

Ext:

Zip Code

(Area code required)

Fax Number:
(including area code)

(Area code required)

Save and Continue
Privacy Act 09 -25 -0165

Applicant Identifying Information
Applicant's Name:
Organization:
Instructions: The applicant has provided the statement linked below describing his/her research accomplishments. Please review this statement and
indicate your concurrence by checking the box below. You may edit the statement and submit a revised file. Please note that the length is limited to
5000 characters or less including spaces (approximately one typed page).
Review Statement:

Click here to view applicant's statement
To submit a revised statement,
please upload the new file here:
Principal Investigator
Concurrence:

Browse...

Attach File

Instructions: Click the "Browse" button and locate your file. We
accept most word processing formats.

c I concur with this statement.
d
e
f
g
Save & Continue Later

Submit Form

Public reporting for this 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 is displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -14
Privacy Act 09 -25 -0165

Instructions: Please use 5000 characters or less including spaces (approximately one typed page) to provide an assessment of (1) the progress of
the applicant's development as an independent clinical or basic science investigator and (2) the institutional value of the applicant's research. In
discussing the applicant's research accomplishments, please compare the applicant to others with a similar degree of training.
Please attach your
assessment:

Attach File

Browse...

Instructions : Click the "Browse" button and locate
your file. We accept most word processing formats.
Save & Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 30 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 currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to NIH, Project Clearances Office, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA 0925 -0361. Do not return the completed form to this
address.
NIH Form 2674 -14
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in

progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

OMB No. 0925-0361
Form Approved for use through xx/xx/xxxx
Click Here to see burden statement

Apply Here

NIH 2674-15
If you are a Research Supervisor/Principal Investigator, Recommender, or Organizational Official who has been asked to
complete a form on behalf of an LRP applicant, Click here to log in!

Apply Here
Get started with your LRP application by telling us who you are. Please enter the information below. If you experience
any problems, please contact the LRP Help Desk at [email protected] or call 866 849-4047 for assistance.
Your Name:
First

Middle

Last

Suffix

Your Email Address:
Reenter Email Address:
Social Security
Number:

Note: We collect your Social Security Number [SSN] to
verify your identity, to determine your eligibility for loan
repayment assistance and to keep track of the federal
funds you receive. We also use your SSN for loan
repayment and servicing purposes under the Loan
Repayment Program. We also use this information to
determine whether you are eligible for loan repayment and
the amount of that assistance. See Privacy Act
information for additional information.
Submit

Already have a password? Click here to log in!

Forgot your password? Click here!

Registration Form
Please enter the information below. If you experience any problems, please contact the LRP Help
Desk at [email protected] or call 866-849-4047 for assistance.

Your Email
Address:
Create Password:
Reenter Password:

Create Security
Question:
Create Security
Answer:

Instructions: Password must be at least 8
characters long, can not contain any part of the
email address and must include one character
from at least 3 of the following 4 types:
1. Uppercase (A-Z)
2. Lowercase (a-z)
3. Numeric (0-9)
4. Symbol (~!@#$%^&*())
Instructions: The question and answer you
provide will allow you to reset your password in
the event you can no longer remember it.
Examples of questions with answers that are
easy to remember but known only by you are:
l What is my Mother’s maiden name?
l What is the name of the city where I was
born?
l What is the name of my favorite pet?

Submit

Already have a password? Click here to login!

Application System Login
Log in here if you are:
Completing or checking the status of your own application.
Providing information and certifications in support of an
applicant.
Your Email Address:
l
l

Password:

Submit

Forgot your password? Click here!
Applying to the program and don’t have a Password? Click here to
apply!

Participant Login
If you are a Participant and you have been notified that your
repayment portfolio is now available, Click here.

Step 1 of 2: Basic Information
To start your application, provide some basic information about yourself. Once these questions are answered, we
can provide the correct forms to apply to the Loan Repayment Program.
Your Name:
First

Type of
Application:

Are
You Applying
for an
Intramural or
Extramural
Loan
Repayment
Program?

Middle

Last

Suffix

j New
k
l
m
n
j Renewal/Extension
k
l
m
n

j Intramural
k
l
m
n

Note: If you are an NIH employee or have been offered employment, please check
"Intramural". Otherwise, please check "Extramural".

j Extramural
k
l
m
n

Save and Continue
Privacy Act 09 -25 -0165

Step 2 of 2: Questions for Extramural Applicants - Section Displayed for EXTRAMURAL ONLY
Your Principal Investigator/Research Supervisor will be
asked to complete a recommendation form on your
behalf, to concur with your research project description
and to provide information on your research training

j I have a Principal Investigator / Research Supervisor
k
l
m
n
j I am an Independent Researcher and do not have a Research
k
l
m
n
Supervisor

and laboratory environment.
Name of NIH Loan Repayment Program
for which you are applying:

j Clinical Research LRP
k
l
m
n
j Pediatric Research
k
l
m
n
LRP
j Clinical Research LRP
k
l
m
n
for Individuals from
Disadvantaged
Backgrounds
(Click here for
eligibility
requirements and
special instructions.)
j Contraception and
k
l
m
n
Infertility Research
LRP
j Health Disparities LRP
k
l
m
n

Instructions: Please select the Loan
Repayment Program you wish to apply
for. This selection will guide the
processing and review of your
application. Only one LRP can be
selected.

*Text hidden if 'New'
Renewal Length: Please select one or two year
renewal

j One year renewal
k
l
m
n
j Two year renewal
k
l
m
n

Save and Continue
Privacy Act 09 -25 -0165

Step 2 of 2: Questions for Intramural Applicants - Section Displayed for INTRAMURAL NEW ONLY
Providing the information below is important for the NIH to determine your eligibility to apply to one of the intramural
Loan Repayment Programs. If you are unable to complete this information, please contact the LRP Helpline at 1-866849-4047 for assistance.
Your Position

Title:

INSTRUCTIONS: Please select the position title found on your SF 50, SF52,
USPHSCC Personnel Orders or SPO Commitment Letter.

Select Title

NOTE TO IRTA's AND CRTA's: Individuals hired under the IRTA or CRTA
mechanism are not eligible for consideration for NIH Intramural Loan
Repayment. If you are an IRTA or CRTA, please do not continue with this
application. Click here to read more about LRP Eligibility
Requirements.
Your
Anticipated
Start Date for
Employment
at the NIH:
Name of
hiring Institute
or Center
(IC):
Name of NIH
(Intramural)
Loan
Repayment
Program for
which you are
applying:

Month

Day

Year

Select Institute or Center (IC)
Select Institute or Center

j
k
l
m
n

AIDS Research LRP

j
k
l
m
n

Clinical Research LRP for Individuals from Disadvantaged Backgrounds
(Click here for eligibility instructions and requirements.)
General Research LRP

j
k
l
m
n

Important: Applicants to the NIH intramural LRPs must be a citizen or a non-citizen national of the United States (US) or have
been lawfully admitted for permanent residence at the time of the LRP award. A non-citizen national is a person who, although
not a citizen of the US, owes permanent allegiance to the US. They are generally persons born in possessions of the US (e.g.,
American Samoa and Swains Island). Individuals who have been lawfully admitted for permanent residence must be in
possession of a currently valid Alien Registration Receipt Card (I-551), or must be in possession of other legal verification of
such status.
For complete information on immigration and naturalization laws, please visit the U.S. Bureau of Citizenship and Immigration
Services (BCIS, formerly known as the Immigration and Naturalization Service) Website by clicking here.
Citizenship:
j U.S. Citizen or Non-Citizen National of the U.S.
k
l
m
n
j U.S. Permanent Resident
k
l
m
n

Country of
Citizenship:
Alien Registration #:

Save and Continue
Privacy Act 09 -25 -0165

Step 2 of 2: Questions for Intramural Applicants - Section Displayed for INTRAMURAL RENEWAL ONLY
Providing the information below is important for the NIH to determine your eligibility to apply to one of the intramural
Loan Repayment Programs. If you are unable to complete this information, please contact the LRP Helpline at 1-866849-4047 for assistance.

Name of hiring
Institute or
Center (IC):

Select Institute or Center (IC)
Select Institute or Center

Name of NIH
(Intramural)
Loan
Repayment
Program for
which you are
applying:

j
k
l
m
n

AIDS Research LRP

j
k
l
m
n

Clinical Research LRP for Individuals from Disadvantaged Backgrounds
(Click here for eligibility instructions and requirements.)
General Research LRP

j
k
l
m
n

For complete information on immigration and naturalization laws, please visit the U.S. Bureau of Citizenship and Immigration
Services (BCIS, formerly known as the Immigration and Naturalization Service) Website by clicking here.
Citizenship:

j U.S. Citizen or Non-Citizen National of the U.S.
k
l
m
n
j U.S. Permanent Resident
k
l
m
n
Country of
Citizenship:
Alien Registration #:

Save and Continue
Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.
Public reporting for this collection of information is estimated to average 3 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 currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -15
Privacy Act 09 -25 -0165

Log Out
OMB No. 0925 -0361
Form approved for use through xx/xx/xxxx
Click here to see burden statement

Institutional Information

NIH 2674-16
LRP Tracking Code:

Basic Information (Section hidden if information is already complete)
To access the LRP application system, please provide the following information. After you click "Save and Continue" the next form will
appear on your screen for completion.:
Your Name:
First

Middle

Last

Position/Title:
Organization:
Division/School:
Department/Section:
Address:

j US n
k
l
m
n
j NonUS
k
l
m

State

City

State

Zip Code

Suffix

+4
Telephone Number:
(including area code)

Ext:

(Area code required)

Fax Number:
(including area code)

(Area code required)

Save and Continue
Privacy Act 09 -25 -0165

Section 1 - Applicant's Identifying Information
Name:
Social Security Number:
Applicant's Organization:
Address:
Research Project Title:
Loan Repayment Program
(LRP) Applied For:

Name of PI or PD:
Section 2 - Annual Income or Compensation
Official Signing for the Applicant Organization Completes This Section
The official providing this information is authorized to act for the organization.
Current Annual Income or
Compensation:

$
Instructions:
Annual income or compensation refers to the "institutional base salary," which is the annual amount that the
organization pays for the applicant's appointment, whether the time is spent on research, teaching, patient care, or
other activities. Base salary excludes any income that an applicant may earn outside of duties to the organization (NIH
Guide for Grants and Contracts Notice (NOT-OD-02-030), released on January 25, 2002). For NRSA awardees, this
question refers to funds characterized as compensation, which may be paid to Fellows only when there is an employeremployee relationship and the payments are for services rendered.
Note: The appointment papers, including official documentation of the annual income or compensation as defined
above, will be requested at a later date (if the candidate is accepted into the program).

Section 3 - Certifying Official's Assurances (Section Displayed for Renewal Only)
Instructions: Please provide certification of Institutional Support for this applicant. To qualify for the NIHLRP:
The applicant's research must be funded by a domestic nonprofit or U.S. Government (Federal, state or local) entity. This includes grants and
fellowships. Salary support and/or research funding from a university department is acceptable if the employer is nonprofit. A nonprofit is defined as a
domestic foundation, professional association, or institution if they are exempt from Federal tax under the provisions of Section 501 of the Internal
Revenue Code (26 U.S.C. 501);
This program is not available to full-time Federal government employees. However, part-time Federal employees (working 20 hours/week or less) that
are not compensated as a Federal employee for their research, and engage in the qualifying research for at least 20 hours per week, may be eligible for
LRP payments.
Please call the Help Desk at 866 849-4047 if you have questions on the applicant's eligibility.
b Please provide certification of Institutional Support for this applicant. You have the option to certify to a period of one or two years. You may obtain
c
d
e
f
g
the Contract Renewal Date from the applicant.
j One Year Period n
k
l
m
I am certifying to Institutional Support for a n
i Two Year Period
j
k
l
m

I certify that:
(1) the applicant and/or their research referenced in Section 1 are supported by (a) a domestic non-profit foundation, non-profit professional society,

or other non-profit institution; (b) a Local, City or State Agency; or (c) a grant from a Federal agency, and the applicant does not receive salary from a
for-profit institution/contractor or the federal government for engaging in the named research project;
(2) the applicant will engage in qualified clinical research for 50% or more of his/her work effort (a minimum of 20 hours per week based on a 40 hour
week);
(3) that the applicant will be provided the necessary time and resources to engage in the named research project for the specified number of years
from the renewal date of their LRP contract; and
(4) that the named research project complies with applicable Federal, state and local laws (e.g., applicable human subject protection regulations) and
is not research for which funding is prohibited by Federal law.
I further certify that the applicant's annual income or compensation 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.
Save & Continue Later

Submit Form

Section 3 - Certifying Official's Assurances (Section Displayed for New Only)
Instructions: Please provide certification of Institutional Support for this applicant. To qualify for the NIHLRP:
The applicant's research must be funded by a domestic nonprofit or U.S. Government (Federal, state or local) entity. This includes grants and
fellowships. Salary support and/or research funding from a university department is acceptable if the employer is nonprofit. A nonprofit is defined as a
domestic foundation, professional association, or institution if they are exempt from Federal tax under the provisions of Section 501 of the Internal
Revenue Code (26 U.S.C. 501);
This program is not available to full-time Federal government employees. However, part-time Federal employees (working 20 hours/week or less) that
are not compensated as a Federal employee for their research, and engage in the qualifying research for at least 20 hours per week, may be eligible
for LRP payments.
Please call the Help Desk at 866 849-4047 if you have questions on the applicant's eligibility.
c
d
e
f
g

Please provide certification of Institutional Support for this applicant.
I certify that:
(1) the applicant and/or their research referenced in Section 1 are supported by (a) a domestic non-profit foundation, non-profit professional society,
or other non-profit institution; (b) a Local, City or State Agency; or (c) a grant from a Federal agency, and the applicant does not receive salary from
a for-profit institution/contractor or the federal government for engaging in the named research project;

(2) the applicant will engage in qualified clinical research for 50% or more of his/her work effort (a minimum of 20 hours per week based on a 40
hour week);
(3) that the applicant will be provided the necessary time and resources to engage in the named research project for two years from the date a LRP
contract is executed (between June-August 2008) ; and
(4) that the named research project complies with applicable Federal, state and local laws (e.g., applicable human subject protection regulations)
and is not research for which funding is prohibited by Federal law.
I further certify that the applicant's annual income or compensation 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.

Save & Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 5 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
is displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -16
Privacy Act 09 -25 -0165

Please periodically click SAVE & CONTINUE in order to not lose work in
progress. You will automatically be logged off the LRP Web site if you have
not moved to a new page in any one hour time period.

NATIONAL INSTITUTES OF HEALTH
US DEPARTMENT OF HEALTH AND HUMAN SERVICES

NIH LOAN REPAYMENT PROGRAMS / LOAN DATA VERIFICATION FORM

NIH 2674-17
OMB No. 0925-0361
Form Approved For Use Through xx/xx/xxxx

SECTION 1 - Information Provided By Applicant
APPLICANT INFORMATION
Name
SSN
Acct #

LENDING INSTITUTION

LOAN DEFERMENT INFORMATION
Deferment Status?
Deferment From
Deferment To
Interest Bearing
LOAN FORBEARANCE INFORMATION
Forbearance Status?

SERVICING AGENT

Forbearance From
Forbearance To
Interest Bearing
LOAN INFORMATION
Date of Loan

Currently Repaying Loan

Original Amount of Loan

Date Repayment Started

Current Interest Rate

Are Payments Up to Date?

Current Payoff Amount

Type of Loan

Payoff Valid Through Date
Monthly Payment Amount

Date For Which
Information is Accurate

SECTION 2 – Lending Institution/Servicing Agent Completes This Section
Instructions: Please verify the information in Section 1; make any corrections next to the item(s) in question. Complete Section 2 and
return this form by FAX to 1-866-849-4046 or by US Mail to Office of Loan Repayment, National Institutes of Health, 6011 Executive
Boulevard, Suite 206, MSC 7060, Bethesda, MD 20892-7060. If you have any questions about completing this form call the LRP
Helpline at 1-866-849-4047.
Lending Institution/Servicing Agent’s Certification
The undersigned states that, to the best of his or her knowledge, the loan identified above is a bona fide legally enforceable
institutional, State, or Government educational loan made for the purpose of meeting the borrower s costs of attending a college or
university, and that the information provided in section 1 is correct. Or, I have indicated in section 1 the corrections needed next to the
item(s) in question.

.
Name and Title of Authorized Official for Lending Institution (Please Print)
.
.
.
.
.
.
.
.
Federal Tax Identification Number / EIN (required for sending payments)
.
Signature

.
Date

Public reporting burden for this collection of information is estimated to average 75 minutes for section 1 and 20 minutes for section 2, 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 currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, Attention: PRA 0925-0361. Do
not return the completed form to this address.
NIH 2674-17
Privacy Act 09-25-0165

Log Out
OMB No. 0925 -0361
Form approved for use through xx/xx/xxxx
Click here to see burden statement

Citizenship Information

NIH 2674-18
LRP Tracking Code: :

Important: Applicants to the NIH extramural LRPs must be a citizen or a non-citizen national of the United
States (US) or have been lawfully admitted for permanent residence at the time of the LRP award. A noncitizen national is a person who, although not a citizen of the US, owes permanent allegiance to the US. They
are generally persons born in possessions of the US (e.g., American Samoa and Swains Island). Individuals
who have been lawfully admitted for permanent residence must be in possession of a currently valid Alien
Registration Receipt Card (I -551), or must be in possession of other legal verification of such status.
For complete information on immigration and naturalization laws, please visit the U.S. Bureau of Citizenship
and Immigration Services (BCIS, formerly known as the Immigration and Naturalization Service) website by
clicking here.
Citizenship:

j U.S. Citizen or Non-Citizen National of the U.S.
k
l
m
n
j U.S. Permanent Resident
k
l
m
n

Country of Citizenship:
Alien Registration #:

Save and Continue Later

Submit Form

Public reporting for this collection of information is estimated to average 5 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 is displays a currently valid
OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974,
Attention: PRA 0925 -0361. Do not return the completed form to this address.
NIH Form 2674 -18
Privacy Act 09 -25 -0165

Verification of
U.S.
Citizenship or
Permanent
Residency
Status

OMB No. 0925 -0361
Form Approved for use through xx/xx/xxxx
Click here to see burden statement

Instructions: Please print, complete, sign and fax this form along with
photocopies of the documents indicated below without a cover page to 866-8494046.

NIH 2674-18
Name:
LRP Tracking Code:

Continue

The National Institutes of Health (NIH) Extramural Loan Repayment Program must confirm your
citizenship status in order to process your application. You are only eligible for a LRP award if you
provide documented evidence that you are: 1) a U.S. Citizen; 2) a U.S. National; or 3) a Permanent
Resident of the U.S. This form and photocopies of the supporting document(s) must be received by
facsimile and approved by the NIH before funds can be awarded under the LRP.
Section 1 - Citizenship or Permanent Residency Status Documentation
Instructions: Please check one box in Section 1 to indicate the source document(s) you are submitting to verify
your citizenship status. Be sure to include photocopies of the document(s) you indicate below at the same time
you fax this form.
Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying
possession of the U.S.
Certificate of U.S. Citizenship (Form N-560 or N-561)
Certificate of Naturalization (Form N-550 or N-570)
United States Passport (expired or unexpired)
Alien Registration Receipt Card with photograph (I -151 or I-551)
Other documentation of Permanent Residency Status as permitted by the U.S. Bureau of
Citizenship and Immigration Services (BCIS, formerly known as the Immigration and Naturalization
Service) regulations. (For more information, visit the BCIS website at
http://www.immigration.gov/graphics/index.htm ).
Please indicate the BCIS document you are using: ____________________________________
Section 2 - Certification by Applicant
I certify that the information given in this application is true, complete, and accurate to the best of my knowledge
and does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of
the omission. I understand that the information given may be investigated and that any false representation is
sufficient cause for rejection of the LRP application, or, if awarded loan repayment, that I am liable for return of
all awarded funds and, further, that any false statement may be punished as a felony under 18 USC § 1001. I
am aware that any false, fraudulent, or fictitious statement may, in addition to other remedies available to
the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.

____________________________________________________
Signature (sign your full name in ink)

_____________________
Date
Continue

Public reporting for this collection of information is estimated to average 5 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 currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892 -7974, Attention: PRA
0925 -0361. Do not return the completed form to this address.

NIH 2674-18
Privacy Act 09 -25 -0165

Logged in as

Log Out

OMB No. 0925 -0361
Form approved for use through xx/xx/xxxx
Click here to see the burden statement

Funding Information

NIH 2674-19
LRP Tracking Code:

Instructions: Indicate below the non-profit source(s) of the funding that will support your research activities
over the term of the LRP contract. If your research is supported by grants it is not necessary for you to be
named on the grant to include the grant information. If your non-profit employer is one of your top three non profit funding sources list your non-profit employer in Section 1.
At least one non-profit or NIH funding source must be identified. Funding information will be used for NIH
program evaluation only. The source of your funding will not be used in the review of your application.
This form will lock only when you submit the complete application.
Section 1 - Non-Profit or Government Research Funding Sources - Not From NIH
Instructions: Complete this section if your research will be supported entirely, or in part, by non-profit or
government funding sources. List up to three non-profit or government funding sources in descending order
of funding amount. Include your non-profit employer if your non-profit employer is one of your top three nonprofit funding sources. If funding will start in the future list the anticipated date of funding as the start date.
Only list grant support from the NIH in Section 3 and National Research Service Awards (NRSA) Fellowships
support in Section 2 .
Non-Profit Funding Source #1
Name of
Funding
Organization:

(150 character limit)

Title of
Grant/Award:

(1000 character limit)

Amount of
Funding:

Funding
Category
Award Status
Are you the PI
on this Grant?

$US

Note: List all funds (direct and indirect) for
all years of the grant or award. Please
provide estimate if pending review.

j Salary n
k
l
m
n
j Non-Profit Organization Grant n
k
l
m
j Institutional Start up Funds n
k
l
m
j State/Local
k
l
m
Govt Grant n
j Federal Grant (non-NIH)
k
l
m
j Pending Review n
k
l
m
n
j Awarded n
k
l
m
j Salary
k
l
m
j Yes n
k
l
m
n
i No
j
k
l
m

Start of Funding:

End of
Funding:

Month

Day

Year

Month

Day

Year

Non-Profit Funding Source #2
Name of
Funding
Organization:

(150 character limit)

Title of
Grant/Award:

(1000 character limit)

Amount of
Funding:

Funding
Category
Award Status
Are you the PI
on this Grant

Note: List all funds (direct and indirect) for
all years of the grant or award. Please
provide estimate if pending review.

$US

Start of Funding:

End of
Funding:

Month

Day

Year

Month

Day

Year

Non-Profit Funding Source #3
Name of
Funding
Organization:

(150 character limit)

Title of
Grant/Award:

(1000 character limit)

Amount of
Funding:

$US

Note: List all funds (direct and indirect) for
all years of the grant or award. Please

provide estimate if pending review.
Funding
Category
Award Status
Are you the PI
on this Grant

Start of Funding:

End of
Funding:

Month

Day

Year

Month

Day

Year

Section 2 - National Research Service Fellowship Award (NRSA) Support
Instructions: Indicate any past, current or future National Research Service Awards (NRSA Fellowship)
funding. If funding will start in the future, list the anticipated date of funding as the start date. If you have
multiple NRSA awards only list the first award.
NIH Award
Number (Project
Number):
Award Status
Start Date for
First Year of
Training Grant:

(Example: 1 T32 CA 811009 - 01 A1S1)

(Not all NIH award number fields are required)

j Pending Review n
k
l
m
n
j Awarded
k
l
m
Length of
Funding:

Month

Day

(months)

Year

Section 3 - NIH Grant Support
Instructions: Complete this section if your research will be supported entirely, or in part, through NIH grants
or contracts. List up to three NIH grants or contracts in descending order of funding amount. If funding will
start in the future, list the anticipated date of funding as the start date. Do not list National Research Service
Awards (NRSA Fellowship, grant numbers starting with T32 or F32) (go to section 2) funding in this section.
NIH Grant/Award #1
NIH
Grant/Award
Number (Project
Number):

(Not all NIH grant number fields are required)

Title of
Grant/Award:

(1000 character limit)

(Example: 1 K08 CA 811009 - 01 A1S1)

Amount of
Funding:

$US

Award Status

j Pending Review n
k
l
m
n
j Awarded
k
l
m

Note: List all funds (direct and indirect) for
all years of the grant or award. Please
provide estimate if pending review.

Start of Funding:

End of
Funding:

Month

Day

Year

Month

Day

Year

NIH Grant/Award #2
NIH
Grant/Award
Number (Project
Number):

(Example: 1 K08 CA 811009 - 01 A1S1)

(Not all NIH grant number fields are required)

Title of
Grant/Award:

(1000 character limit)

Amount of
Funding:

$US

Award Status

j Pending Review n
k
l
m
n
j Awarded
k
l
m

Start of Funding:

Note: List all funds (direct and indirect) for
all years of the grant or award. Please
provide estimate if pending review.

End of Funding:

Month

Day

Year

Month

Day

Year

NIH Grant/Award #3
NIH
Grant/Award
Number (Project
Number):

(Not all NIH grant number fields are required)

Title of
Grant/Award:

(1000 character limit)

(Example: 1 K08 CA 811009 - 01 A1S1)

Amount of
Funding:

$US

Award Status

j Pending Review n
k
l
m
n
j Awarded
k
l
m

Start of Funding:

Note: List all funds (direct and indirect) for
all years of the grant or award. Please
provide estimate if pending review.

End of Funding:

Month

Day

Year

Month

Save and Continue Later

Day

Year

Submit Form

Public reporting for this collection of information is estimated to average 40 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 is displays a
currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892 -7974, Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674 -19
Privacy Act 09 -25 -0165

File Type	application/pdf
File Title	file://W:\HELP DESK\OMB Submission\New OMB Forms\2674-1 App Inf
Author	reedp
File Modified	2008-01-30
File Created	2007-11-26