Form 1 Certification

OMB No. 0925-0299
Form approved for use through 03/31/2014

U.S. Department of Health and Human Services
National Institutes of Health
Undergraduate Scholarship Program (UGSP) – Undergraduate Institution Certification
Applicant’s Instructions – Please complete Section A. Undergraduate Institution’s Instructions – Please complete Section B and return the
Give this form and one of the return envelopes to the
form in the envelope provided, or mail to National Institutes of Health Undergraduate
financial aid office at the school at which you are
Scholarship Program, 2 Center Drive, Room 2W11A (MSC 0230), Bethesda, Maryland
enrolled or will be enrolled starting September 2011.
20892-0230. If you have any questions, call 301-496-2555 or e-mail .
Section A – The applicant completes this section.
1. Applicant’s Name (last, first, middle)

1a. Other Names Used on Official Documents (last, first, middle)

2. Student Identification Number
3. Assigned UGSP Application Number
I authorize the institution indicated in Section B to release information about my academic, financial, service, and other pertinent information to
administrators of the NIH Undergraduate Scholarship Program (UGSP) and to other authorized Government officials. This release is valid for sixmonths after completion of UGSP requirements.
Signature (Sign your full name in ink)______________________________________________________________ Date______________________
Section B – To be completed by Academic Institution Financial Aid Office
1. Enrollment Status
-Do you expect that this student will be enrolled full-time for the 2012-2013 academic year? yes  no
-If current enrolled, is this student currently in good standing? yes  no
-Has this student been accepted for enrollment as a full-time student for 2012-2013 academic year? (For new students) yes  no
-What is the anticipated graduation date for this student? yes  no
2. Exceptional Financial Need Status – Does this student qualify for ‘exceptional financial need’ (EFN) status as defined by the Secretary,
Department of Health and Human Service? (See page 2 for definition of EFN) yes  no
3. Addition Sources of Financial Support – The above
4. Calculation of Eligible Tuition, Education and Living Expenses for 2012-2013
named student (Section A) has been awarded the following
– The UGSP scholarship covers up to $20,000.00 per academic year toward (1)
financial aid for 2012-2013 academic year:
tuition, (2) reasonable education expenses, and (3) reasonable living expenses.
-Tuition: What is the tuition amount for this student?
$________________Student Loans
$________________Tuition
$________________Institutional Scholarships
-Educational Expenses: What are the average educational expenses for the
$________________Non-Institutional Scholarships / Grants categories listed below?
$________________Books
$________________Total Financial Support
$________________Laboratory Fees
$________________Other (specify)____________________
Continuation of this financial aid support (will  will not)
$________________Other (specify)____________________
be reduced by the receipt of NIH UGSP funding.
-Living Expenses: What are the average room, board, and transportation expenses?
$________________Room
$________________Board
$________________Transportation
$________________Total Expenses
5. Certification of Academic Institution Financial Aid Office
The undersigned institutional representative certifies that, to the best of his/her knowledge, the information reported above is accurate. This
Certification should include the school’s seal or office stamp.
Name of School ________________________________________________________________________________________________________
Financial Aid Administrator’s Name (please print)_______________________________________Title____________________________________
Signature______________________________________________________________________________Date____________________________
Telephone____________________Fax Number____________________Email Address_______________________________________________
Public reporting for this collection of information is estimated to average 15 minutes per response, 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, ATTN: PRA (0925-0299). Do not return
the completed form to this address.

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Instructions for Undergraduate Institution Certification Form NIH 2762-3
Exceptional Financial Need Status Identification of Individuals from Disadvantaged Backgrounds (Scholarship applicants must be from
disadvantaged backgrounds)
A student from a disadvantaged background is one who comes from a family with an annual adjusted gross income below a level
based on 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, DHHS, for use in all health professions programs.
Qualification of EFN Status. Applicants who qualify as having EFN status must provide the Financial Aid Director of their undergraduate
institution total financial information, including: parent’s income and spouse’s income (if applicable), regardless of the student’s taxable
status, and must be of EFN, as defined by the Secretary, DHHS, (see above). The Financial Aid Director must certify this information
and the institution’s certification of an applicant’s EFN status must be included with the UGSP application package.
The Secretary, DHHS, will periodically publish these low-income levels in the Federal Register. (Please see the table below for the
most recent determination of low-income levels). If family income for the most recent calendar year is less than the income level
indicated on the chart below for the appropriate family size, students fulfill the definition of an individual having exceptional financial
need (EFN). Students certified as being of EFN are considered to be from disadvantaged backgrounds.
Low-Income Levels—Secretary DHHS
Federal Register, Vol. 76, No. 51 /March 16, 2011 Notices page 14417.
Persons in Family
Family Income Level
(Includes only dependents listed on Federal income tax forms) (Adjusted gross income, rounded to the nearest $100)
1
$21,780
2
$29,420
3
$37,060
4
$44,700
5
$52,540
6
$59,980
7
$67,620
8
$75,260
For families with more then 8 persons, add $3,820 for each additional person
Privacy Act Notice
The Privacy Act of 1974 (5 USC 552a) requires that a Federal agency provide the following notification to each individual whom it asks
to supply information. This information is contained in the System of Records of the Department of Health and Human Services
(DHHS) numbered 09-25- 0165, entitled National Institutes of Health Office of Loan Repayment and Scholarship (OLRS) Records
System, HHS/NIH/OD. An update of this system of records was published in the Federal Register on February 8, 2002 (67 Fed. Reg.
6043).
* The authority for collection of the requested information is contained in Sections 487A-F and Section 485G of the PHS Act
(42USC288-1,2,3,4,5,5a,6; and 42USC287c- 33), and Public Laws 100-607, 101-597, 103-43, 106-310, 106-505, 106-525, and 106554. The Internal Revenue Code at 26 USC 6109 requires the provision of the Social Security number (SSN) for the receipt of funds.
* The principal purposes of information that you, the applicant or participant, furnish are (1) to determine your eligibility for loan
repayment or scholarship under Sections 487A-F and Section 485G of the PHS Act, including verification of the existence and purpose
of your educational loan(s), and determination of the amount(s) that are eligible for repayment under the NIH Loan Repayment and
Scholarship Programs (LRSPs); and (2) to negotiate and verify the transfer of loan repayments, scholarship awards, and tax
reimbursements to participants and to the Department of the Treasury (Treasury), Internal Revenue Service (IRS).
* The principal purposes of information that you, the lender, furnish are (1) to determine an individual applicant or participant’s eligibility
for loan repayment under Sections 487A-C, E and F, and Section 485G, of the PHS Act, including verification of the existence and
purpose of an individual’s educational loan(s), determination of the amount(s) that are eligible for payment under the NIH LRSPs; and
(2) to negotiate and verify the transfer of a loan repayment to a participant’s loan account.
* The principal purposes of the information that you, the undergraduate institution, furnish are (1) to determine an individual applicant
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or participant’s eligibility for scholarship award under Section 487D of the PHS Act, including verification of the amounts of tuition and
qualifying educational expenses, including room and board; and (2) to determine an applicant’s disadvantaged background status.
* While disclosure of the information is not mandatory, you must provide the information requested to obtain loan repayment and
scholarship benefits authorized by Sections 487A-F and Section 485G of the PHS Act.
* The information you provide will be made available to Federal employees responsible for administering the NIH LRSPs to determine
your eligibility for loan repayment and scholarship awards, as described above.
* The information you provide will not be disclosed without your consent to anyone outside of DHHS in a manner that identifies you,
except as permitted by the Privacy Act.
(See Routine Uses 1-17 for Additional Disclosures.)
* Certifying on NIH 2674-1, “Applicant Information,” authorizes the disclosure of information that confirms you are not under a service
obligation, certifying on NIH 2674- 4, “Loan Information,” authorizes the disclosure of information to the lenders and their authorized
collection agents to confirm that your loans are current in their repayment status, and certifying on NIH 2674-10, “Institutional
Information,” authorizes the disclosure of information to the extramural research institutions and their authorized officials to confirm that
you are eligible for the loan repayment program and able to fulfill the two-year service obligation.
* Certifying on NIH 2762-1, “Undergraduate Scholarship Applicant Information,” NIH 2762-2, “Applicant Information:
Recommendation,” and NIH 2762-3, “Undergraduate Institution Certification,” authorizes the disclosure of information to the
undergraduate institution to determine your eligibility for participation in the Undergraduate Scholarship Program, to confirm your
eligibility for disadvantaged background status and non-delinquent loan status, and to disclose your educational expenses.
Provision of Your Social Security Number Under Public Law 93-579, Section 7(b), Privacy Act of 1974
* Provision of your SSN is required for participation of the LRSPs. This provision is required, as provided in the Internal Revenue Code
26 USC 6109.
* Provision of your SSN is needed to verify the financial information provided in your application. Your SSN will be given to the
Treasury to disburse Federal funds in connection with the program benefit. Your SSN will be used for identification with the records of
the Treasury and DHHS in the event of the loss or theft of repayment checks or scholarship awards or other difficulties arising from this
transaction. Your SSN will be given to consumer reporting agencies to obtain a commercial credit report that verifies your ability to
repay debts owed to the Federal Government.
* Your SSN will be disclosed to the IRS when making loan repayments or scholarship awards and tax reimbursement payments to the
IRS for the benefits you receive under the LRSPs. Your SSN will be disclosed to the IRS to obtain a current mailing address if you
default on your service obligation, and to other Federal agencies, commercial credit bureaus, or collection agencies to offset or collect
delinquent debts.
Routine Uses as Permitted by the Privacy Act
* A Congressional office in response to a written request by the applicant or participant concerning his or her record;
* The Department of Justice or to a court in the event of litigation;
* The appropriate agency, whether Federal, foreign, State, local, or tribal, in the event that a system of records indicates a violation or
potential violation of law;
* DHHS contractors for the purpose of processing or refining records, and/or for the purpose of evaluating the programs covered by
the system;
* Private parties such as present and former employers, references listed on application and associated forms, other references, and
educational institutions to determine if an applicant is suitable for participation in the NIH LRSPs;
* A consumer reporting agency (credit bureau) to obtain a commercial credit report to establish an individual’s creditworthiness; to
assess and verify his or her ability to repay debts owed to the Federal Government; and to determine and verify the eligibility of loans
submitted for repayment;
* Another Federal agency so that the agency can effect a salary offset for debts owed by Federal employees, or so that the agency
can effect an authorized administrative offset; or to the IRS to request an individual’s current mailing address to locate him or her to
collect or compromise debt, or to have a commercial credit report prepared;
* Another agency that has asked DHHS to effect a salary or administrative offset to help collect a debt owed to the United States;
* The IRS to find out whether the applicant has a delinquent tax account;
* The IRS to report as taxable income the written-off portion of a debt owed by an individual to the Federal Government when a debt
becomes partly or wholly uncollectible;
* Debt collection agents, other Federal agencies, and other third parties who are authorized to collect Federal debts and information
necessary to identify a delinquent debtor or defaulting participant;
* Any third party that may have information about a delinquent debtor’s or defaulting participant’s current address;
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* Other Federal agencies that also provide loan repayment or scholarship at the request of these Federal agencies in conjunction with
a matching program conducted by these agencies to detect or curtail fraud and abuse in Federal loan repayment and scholarship
programs, and to collect delinquent loans or benefit payments owed to the Federal Government;
* The IRS to offset any income tax refunds that may be due to the individual against the debt;
* Other Federal agencies, debt collection agents, and other third parties who are authorized to collect a Federal debt to identify an
individual who is delinquent in loan benefit payments owed to the Federal Government and the nature of the debt;
* Officials or representatives of grantee institutions in connection with the review of a Loan Repayment Program (LRP) application or
performance or administration under the terms and conditions of the LRP award; or in connection with problems that might arise in
performance or administration of the LRP contract.
* Designated school coordinators to determine scholarship support, to inform recipients about their service obligations to NIH, and to
verify service deferments for certain Undergraduate Scholarship Program participants; and
* DHHS contractors to recruit, screen, and match health professionals for NIH employment in qualified research positions; and to
references, medical licensing boards, and NIH officials to evaluate the applicant’s professional qualifications, experience, and
suitability.

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