1 Application

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

Telephone Number:

State

-

6
Zip Code

+4

-

(Area code required)

Fax Number:
(optional)

-

-

(Area code required)
Email:
(optional)

Section 3. Employment (or School) Contact Information

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

Position Title:

6

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

-

-

6
Zip Code

+4

Ext:

(Area code required)

Alternate Contact Number:
(optional)

-

-

Ext:

(Area code required)
j Cell
k
l
m
n

Fax Number:

j Pager
k
l
m
n

-

-

(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. Do not exceed
5 pages.
Instructions: Click the "Browse"
button and locate your file. We accept
most word processing document
types.

Undergraduate Degree:

Year

6

Degree

6

Major/Field of Specialization:
Conferring Institution:

Medical/Dental Degree:

Year

6

6 NOTE: If MD/Ph.D. complete information

Degree

for M.D. in this block and information for
Ph.D. separately under "Highest Graduate
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

5

6

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)

Select a Specialty
Allergy and Immunology
- Clinical and Laboratory Immunology
Anesthesiology
- Pediatrics Anesthesiology
- Critical Care Medicine
- Pain Management

5

6

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
Highest Graduate Degree (1):

Year

6

Degree

6

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)

5

6

Graduate Degree (2):

Year

6

Degree

6

Major/Field of Specialization:
Conferring Institution:

Graduate Degree (3):

Year

6

6

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?

j Yes (Please provide an explanation below) n
k
l
m
n
j No
k
l
m
5

6

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?

j Yes (Please provide an explanation below) n
k
l
m
n
j No
k
l
m
5

Please answer "No" if you are
supported by a National
Research Service Award
(NRSA) Fellowship ( T32/F32 )
through the NIH.

6

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 1866-849-4047. Click here for examples of service obligations.
Do you owe a service pay-back
obligation?

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

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?

6

Month

6

6

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/Ethnicity/Race/National Origin/Disability Status
Gender:

6

j Male
k
l
m
j Female n
k
l
m
n

Are you Hispanic or Latino?

c Yes
d
e
f
g

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

A person of Mexican, Puerto Rican,
Cuban, Central or South America, or other
Spanish cultures or origins, regardless of
race. The term, “Spanish origin,” can be
used in addition to “Hispanic or Latino.”

c No
d
e
f
g

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

g Asian
c
d
e
f

c Native Hawaiian or Other Pacific Islander
d
e
f
g
c Black or African American
d
e
f
g

g White
c
d
e
f

Definition of Category
A person having origins in any of the
original peoples of North American and
South America (including Central
America), 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. Terms such as
“Haitian” or “Negro” can be used in
addition to “Black or African American.”
A person having origins in any of the
original peoples of Europe, the Middle
East, or North Africa.

c Do Not Wish to Provide
d
e
f
g

Disability Status:

5

6

Date of Birth:

6

Month
Section 8. Certifications
Certification of Nondelinquent Status

6

6

Day

Year

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.

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
d
e
f
g
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 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.
Instructions: (Displayed for INTRAMURAL RENEWAL APPLICANT ONLY) Use 12,000 characters or less including spaces
(approximately three single-spaced, typed pages) to briefly describe your previous research training experience and your short-term
academic and research objectives. In addition, please give a brief description of your plans for your research career in the immediate
future (the next two to five years) and in the time following that (five to ten years). 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.
Save and Continue Later

Submit Form

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

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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. Click here 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 30 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:

6 Other:

Select Lender

Address:

State 6
City

State

Zip Code

+4

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

State 6
City

State

Zip Code

+4

Section 2 - Loan Details
Original Amount of
Loan:

$

Date When Loan was
Disbursed:

6

Month

Monthly Payment
Amount:
Payoff Balance:

6

Year

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

$

$

Payoff valid through
what date?

6

Month
Current Interest Rate

6

Day

6

Day

6

Year

of Loan:
Interest Type:

%
Select Interest Type 6

Loan details accurate
as of what date?

6

Month

6

Day

6

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:

6

Month

End date of current
period:

6

Month

Interest Bearing?

6

Day

6

Year

6

Day

6

Year

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

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

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

Are your payments
up to date?

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

If this is a
consolidated loan,
were the underlying
loans ever defaulted,
past due or
delinquent, incurring
late fees, penalty
fees or collection
costs?
Is this loan
consolidated with a
spouse or another
individual?

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

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

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

Date Loan
Repayment Started:

6

Month

6

Day

6

Year

Purpose of Loan:
Type of Loan:

Select Type of Loan

Section 5 - Certification by Applicant/Borrower

6 Other:

g 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
c
d
e
f
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 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.

Delete This Form

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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 Division of Loan Repayment or the EOD date for new hires,
whichever occurs later.

Personnel Select One
Documentation

Type of Assignment:

 Permanent




 Temporary





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 Division of Loan Repayment at 1866-849-4046. 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
 Yes (or N/A)




be extended?
 No




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 0D\ 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

Save and Continue Later

Submit Form

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

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). 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:

5
6
(Please limit your response to 256 characters or less.)

Shortened/General
Title:

5
6

Instructions: Enter a
short title that
summarizes your
research.

(Please limit your response to 81 characters or less.)

Please attach your
research activities

Attach
File

Browse...

Instructions: Click
the "Browse" button

description:

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.

Save and Continue Later

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 20892-7974, 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:
(including area
code)

State

-

-

6

Zip Code

+4

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:

5
6

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. You should also include a brief description of the source of funding for the research the applicant is engaged in as well as your
funding sources.
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 include a summary of your prior experience as a mentor of other
investigators.
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...

Click here for instructions on
completing a Biosketch and for a
sample Biosketch in PDF or Rich
Text Format (rtf). Do not exceed 5
pages.

Section 4 - Biosketch of Principal Investigator/Research Supervisor
Please submit your
Biosketch:

Attach File:

Section 5 - Principal Investigator/Research Supervisor Assurance

Browse...

Click here for instructions on
completing a Biosketch and for a
sample Biosketch in PDF or Rich
Text Format (rtf). Do not exceed 5
pages.

c I certify that (1) the statements herein are true, complete, and accurate to the best of my knowledge; (2) I agree to accept
d
e
f
g
responsibility for the scientific 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 60 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 866-849-4046. 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
d
e
f
g
concur with and assess your research accomplishments.

Please note: If you are receiving LRP benefits currently and you have changed institutions, you need to notify us by sending an email to
[email protected] or by calling 1-866-849-4047. Completing an online renewal application is not sufficient notice of a change of institution. .

*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...

Save and Continue Later

EmailAddress

Instructions: Click the "Browse" button and
locate your file. We accept most word
processing formats.
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 (black ink preferred), and fax this form without a cover page to 866-849-4046.
Print
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 certify that I am a United States Citizen, United States
National or Permanent Resident of the United States. 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:

6

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

Disadvantaged Background Documentation

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) 
 I have received a loan from the Health Professions Student Loans



(HPSL) or Loans for Disadvantaged Student Program.

(2) 
 I have received a scholarship from the U.S. Department of Health and



Human Services under the Scholarship for Individuals with
Exceptional Financial Need.

(3) 
 I have a written statement from my former health professions school



(s) that I qualified for Federal disadvantaged assistance during
attendance at the school.

Important: You must submit this documentation to the NIH Division of Loan
Repayment 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 four hour time period.

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

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
Institute on Minority Health and Health Disparities (NIMHD), 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/NIMHD 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 NIMHD
Director
Subject to the availability of funds appropriated by the U.S. Congress for the
NIH and/or the LRP, the Secretary/NIMHD 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:
a. undergraduate, graduate, and health professional school tuition expenses;
b. other reasonable educational expenses required by the school(s)
attended, including fees, books, supplies, educational equipment and
materials, and laboratory expenses; and
c. the cost of room and board, and other reasonable living expenses as
determined by the Secretary/NIMHD Director.
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/NIMHD Director and he or she is engaged in qualifying research.
NIH will repay the 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;

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 $20,000 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/NIMHD 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/NIMHD Director will repay the loans in the following
order, unless the Secretary/NIMHD 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/NIMHD 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
The participant agrees to:
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/NIMHD 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;
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.

NIH 2674-12 (PAGE 1)
Revised 11-10

Privacy Act 09-25-0165

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/NIMHD 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/NIMHD Director or the Loan
Repayment Program participant. Based upon the recommendation of the
Secretary/NIMHD 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.

3. Penalties for Failing to Complete the Service Obligation - In
accordance with the statute, the Secretary/NIMHD 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 (1) and (2) 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/NIMHD 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
non discharge 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/NIMHD 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/NIMHD 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/NIMHD Director or his/her authorized representative must sign this contract before it
becomes effective.
Applicant’s Name (Please Print)
Applicant’s Signature
Date
Secretary of Health and Human Services/NIMHD Director or Designee

Date

Contract Period
From: _______________

To: ________________

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)
Revised 11-10

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)

Fax Number:
(including area
code)

State

-

-

6

Zip Code

+4

Ext:

(Area code required)

-

-

(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 protected from disclosure by officials of the NIH Loan Repayment Programs according to Privacy Act
System of Records #09-25-0165.
Section 1 - Applicant Information
Name:

Applicant's Organization:
Loan Repayment Program
(LRP) Applied For:

Clinical Research LRP

Section 2 - Recommendation
Notice: This page will automatically log you off after 30 minutes, even if you are actively entering information into the form,
unless you click Save and Continue or Submit button. The 30 minute time-out resets each time you click the Save and
Continue button. Please periodically click SAVE & CONTINUE in order to not lose work in progress.
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?

5
6
(Please limit your response to 100 characters or less.)

How long have you known the
applicant?
Rating of 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.

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

(Outstanding) n
j1 n
k
l
m
j2 n
k
l
m
j3 n
k
l
m
j4 n
k
l
m
j5 n
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) m
n1 n
j
k
l
j2 n
k
l
m
j3 m
k
l
m
n4 n
j
k
l
j5 n
k
l
m
j6 n
k
l
m
j 7 (Poor) m
k
l
m
n (Don't Know)
j
k
l

Commitment to a career in
[clinical research:]

(Outstanding) n
j1 n
k
l
m
j2 n
k
l
m
j3 n
k
l
m
j4 n
k
l
m
j5 n
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
j2 n
k
l
m
j4 n
k
l
m
j5 n
k
l
m
j6 n
k
l
m
j 7 (Poor) n
k
l
m
j (Don't Know)
k
l
m
j3 n
k
l
m

Likelihood to become an
independent researcher:

(Outstanding) n
j1 n
k
l
m
j2 n
k
l
m
j3 n
k
l
m
j4 n
k
l
m
j5 n
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
j2 n
k
l
m
j3 n
k
l
m
j4 n
k
l
m
j5 n
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
assets that the applicant brings
to his/her research
environment?

5

6
(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)?

5

6
(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

*Text hidden if 'New'
Assess the applicant's
accomplishments over the
past years and what
advantages will be
conferred by continued
research experience?

5

6
(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

What is your overall
recommendation for the
applicant?

(High) m
n2 n
j
k
l
j3 n
k
l
m
j4 n
k
l
m
n6 n
j
k
l
j 7 (Do Not Recommend)
k
l
m
n1 m
j
k
l
j5 m
k
l
m
5

6
(Please limit your response to 2500 characters (approximately 1/2 page) or less.)

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

Save and 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 2674-13
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

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)

6

State

-

-

Ext:

Zip Code

+4

-

(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 register! If you have already registered, 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 Information Center 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
Information Center at [email protected] or call 866-849-4047 for assistance.

Your Email
Address:
Create Password:
Reenter Password:

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:
 What is my Mother’s maiden name?
 What is the name of the city where I was
born?
 What is the name of my favorite pet?

Create Security
Question:
Create Security
Answer:

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:



Password:

Submit

Forgot your password? Click here to recover your password!
Applying to the program and don’t have a Password? Click here to
apply!
Completing form for an applicant and don’t have a Password? Click
here to register!

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

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

 New




 Renewal/Extension





 Intramural





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

 Extramural





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

 I have a Principal Investigator / Research Supervisor




 I am an Independent Researcher and do not have a Research




Supervisor

 Clinical Research LRP




 Pediatric Research




LRP
 Clinical Research LRP




for Individuals from
Disadvantaged
Backgrounds
(Click here for
eligibility
requirements and
special instructions.)
 Contraception and




Infertility Research
LRP
 Health Disparities LRP





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

 One year renewal




 Two year renewal





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.

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 Information Center
at 1-866-849-4047 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







AIDS Research LRP







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







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:

 U.S. Citizen or Non-Citizen National of the U.S.




 U.S. Permanent Resident





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 Information Center
at 1-866-849-4047 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:







AIDS Research LRP







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







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:

 U.S. Citizen or Non-Citizen National of the U.S.




 U.S. Permanent Resident





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

Suffix

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

 US 




 NonUS




State

City

Telephone Number:
(including area code)

State

-

-

Zip Code

+4

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:
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 employer-employee 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 LRP Information Center at 866 849-4047 if you have questions on the applicant's eligibility.
 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 the Contract Renewal Date from the applicant.
I am certifying to Institutional Support for a 
 One Year Period 



 Two Year Period




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 LRP Information Center at 866 849-4047 if you have questions on the applicant's eligibility.
 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.

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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

NIH LOAN REPAYMENT PROGRAMS / LOAN INFORMATION FORM
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
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

For Consolidated Loans Only:
Were only loans associated with the
Applicant included in the
Consolidation?

Date For Which
Information is Accurate

Were the underlying loan ever past due or
delinquent, defaulted or incurred late fees,
penalty fees or collection costs?

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 Division of Loan Repayment, National Institutes of Health, 6011
Executive Boulevard, Suite 206, MSC 7060, Bethesda, MD 20892-7650. If you have any questions about completing this form,
please contact the Division of Loan Repayment at [email protected].
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 15 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 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 (I551), 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. Click here to
visit US Bureau of Citizenship & Immigration Services.
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

NIH 2674-18
Name:
LRP Tracking Code:

Instructions: Please print, complete, sign (black ink preferred), and fax this form
(without a cover sheet) along with photocopies of the documents indicated below to 1866-849-4046.

Print

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 non-profit
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:

5
6
(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

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 Govt
k
l
m
Grant n
Federal
Grant
(non-NIH)
j
k
l
m
j Pending Review n
k
l
m
n
j Awarded n
k
l
m
j Salary
k
l
m
n Yes m
j
k
l
m
n No
i
j
k
l

Start of Funding:
6

6

6

End of
Funding:

6

6

6

Month

Day

Year

Month

Day

Year

Non-Profit Funding Source #2
Name of Funding
Organization:
(150 character limit)

Title of
Grant/Award:

5
6
(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

n Salary n
j
k
l
m
j Non-Profit Organization Grant m
k
l
m
n Institutional Start up Funds m
j
k
l
n State/Local Govt
j
k
l
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:

6

Month

6

6

Day

Year

End of
Funding:

6

Month

6

Day

6

Year

Non-Profit Funding Source #3
Name of Funding
Organization:
(150 character limit)

Title of
Grant/Award:

5
6
(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
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 Govt
k
l
m

Grant n
j Federal Grant (non-NIH)
k
l
m
Award Status

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

Are you the PI on
this Grant

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

Start of Funding:

6

Month

Day

End of
Funding:

6

6

Year

6

Month

6

Day

6

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):

6

-

(Example: 1 T32 CA 811009 - 01)

(Not all NIH award number fields are required)

Award Status

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

Start Date for
First Year of
Training Grant:

6

Month

Day

Length of
Funding:

6

6

(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):

6

-

(Example: 1 K08 CA 811009 - 01 A1S1)

(Not all NIH grant number fields are required)

Title of
Grant/Award:

5
6
(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.

Award Status

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

Start of Funding:

6

Month

Day

End of
Funding:

6

6

Year

6

Month

6

Day

6

Year

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

6

-

(Example: 1 K08 CA 811009 - 01 A1S1)

(Not all NIH grant number fields are required)

Title of
Grant/Award:

5
6
(1000 character limit)

Amount of
Funding:

$US

Award Status

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

Start of Funding:

6

Month

6

6

Day

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

End of Funding:

Year

6

Month

6

Day

6

Year

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

6

-

(Example: 1 K08 CA 811009 - 01 A1S1)

(Not all NIH grant number fields are required)

Title of
Grant/Award:

5
6
(1000 character limit)

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:

6

Month

6

6

Day

Year

End of Funding:

6

Month

Save and Continue Later

6

Day

6

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