Form Attachment 10 Attachment 10 Payment Agreement

Form Approved Through 06/30/2015

OMB No. 0925-0001

Ruth L. Kirschstein National Research Service Award

Payback Agreement

To be completed by Trainees and Fellows before beginning the first 12 months of postdoctoral support.

COMPLETED FORM SHOULD BE MAILED TO THE AWARDING FEDERAL AGENCY GRANTS

MANAGEMENT OFFICE NAMED IN THE NOTICE OF AWARD.

THIS AGREEMENT IS A REQUIRED CONDITION OF
AWARD.
Introduction-Section 1602 of the NIH Revitalization Act of
1993, which was signed into law on June 10, 1993,
contains provisions which substantially modify the service
payback requirements for individuals receiving Ruth L.
Kirschstein National Research Service Awards (NRSA).
These modifications apply to individuals beginning
Kirschstein−NRSA-supported appointments or fellowship
awards on or
after June 10, 1993. Under these
requirements:
•

Predoctoral Kirschstein-NRSA recipients will not incur
a payback obligation;

•

Postdoctoral Kirschstein-NRSA recipients will incur a
payback obligation only during the initial 12 months of
postdoctoral Kirschstein-NRSA support;

•

Postdoctoral Kirschstein-NRSA recipients in the 13th
or subsequent months of Kirschstein-NRSA support
do not incur any additional payback obligation.

Under the new requirements, payback obligations
stemming from postdoctoral Kirschstein−NRSA support
may be discharged in the following ways:
•

By receiving an equal period of postdoctoral
Kirschstein-NRSA support beginning in the 13th
month of such postdoctoral Kirschstein-NRSA
support;

•

By engaging in an e qual period of health-related
research, research training, and/or health-related
activities that averages at least 20 hours per week
based on a full work year;

•

By engaging in an e qual period of health-related
teaching that averages at least 20 hours per week
based on a full work year.

Kirschstein−NRSA appointments or individual awards will
be governed by the service payback requirements
articulated in the National Research Service Award
Guidelines. These guidelines can be found in the NRSA
portion of the most recent version of the NIH Grants Policy
Statement found at: http://grants.nih.gov/grants/policy/
policy.htm.

PHS 6031 (Rev. 06/12) Page 1

I. SERVICE REQUIREMENT
In accepting a Ruth L. Kirschstein National Research
Service Award to support my postdoctoral research
training, I understand that my first 12 months of
Kirschstein-NRSA support for postdoctoral research
training carries with it a payback obligation. I hereby agree
to engage in a m onth of health-related research, healthrelated research training, or health-related teaching for
each month I receive Kirschstein-NRSA support for
postdoctoral research training up to and including 12
months. If I receive Kirschstein-NRSA support for
postdoctoral research training for more than 12 months, I
agree that the 13th month and each subsequent month of
Kirschstein-NRSA-supported
postdoctoral
research
training will satisfy a month of my payback obligation
incurred in the first 12 months. This service shall be
initiated within 2 years after termination of KirschsteinNRSA support. The research, teaching, and/or healthrelated activities shall be on a continuous basis and shall
average at least 20 hours per week of a full work year. For
information regarding deferral of the NRSA obligation due
to participation in the NIH Loan Repayment Program see:
http://www.lrp.nih.gov.

II. FINANCIAL PAYBACK PROVISIONS
I understand that if I fail to undertake or perform such
service in accordance with Section I, the United States will
be entitled to recover from me an am ount determined in
accordance with the following formula:

A = F [(t-s)/t]
Where “A” is the amount the United States is entitled to
recover; “F” is the sum of the total amount paid to me
under the initial 12 m onths of my postdoctoral Ruth L.
Kirschstein National Research Service Award support; “t”
is the total number of months in my service obligation; and
“s” is the number of months of such obligation served.
Except as provided in Section III below, any amount the
United States is entitled to recover from me shall be paid
within the 3-year period beginning on the date the United
States becomes entitled to recover such amount. The
United States becomes entitled to recover such amount 2
years after termination of my Ruth L. Kirschstein National

Research Service Award support if I do n ot engage in
acceptable service payback activities in accordance with
Section I. If I elect to engage in financial repayment before
the end of the 2-year period, the United States becomes
entitled to recover such amount on t he date of my
election. Interest on the amount begins on the date the
United States becomes entitled to recover such amount
and is at the rate fixed by the Secretary of the Treasury
after taking into consideration private consumer rates
prevailing on that date. I understand that I will be allowed
an initial 30-day interest-free period in which to fully pay
such amount, and that I may prepay any outstanding
balance after that period to avoid additional interest. I
further understand that I will be subject to authorized debt
collection action(s) (including any accrued interest and
late fees) should I fail to comply with the payback
provisions of this Section II.

III. CONDITIONS FOR BREAK IN SERVICE,
WAIVER, AND CANCELLATION
I hereby understand that the Secretary of Health and
Human Services:
A. May extend the period for undertaking service, permit
breaks in service, or extend the period for repayment, if
it is determine that:

Agency concerning post-award activities, and agree to
keep the awarding Federal Agency advised of any change
of address and/or name until such time as my total
obligation is fulfilled.

V. PROGRAM EVALUATION
I understand that I may also be c ontacted from time to
time, but no m ore frequently than once every 2 years,
after the termination of this award to determine how the
training obtained has influenced my career. Any
information thus obtained would be used only for statistical
purposes and would not identify me individually.

VI. CERTIFICATION
By signing the certification block below, I certify that I have
read and understood the requirements and pr ovisions of
this assurance and that I will abide by them if an award is
made.
For additional questions
Agreement contact:

regarding

the

Payback

NRSA Payback Service Center
Phone: (301) 594-1835 or (866) 298-9371
[email protected]

1. Such an ex tension or break in service is
necessary to complete my clinical training or to
participate in a NIH Loan Repayment Program;

DO NOT RETURN THE COMPLETED FORM TO THIS
ADDRESS.

2. Completion would be impossible because of
temporary disability; or

VII. MAILING

3. Completion would involve a substantial hardship
and failure to extend such period would be
against equity and good conscience;
B. May waive my obligation, in whole or in part, if it is
determined that:
1. Fulfillment would be impossible because I am
permanently and totally disabled; or
2. Fulfillment would involve a substantial hardship
and the enforcement of such obligation would be
against equity and good conscience;
C. Will, in the event of my death, cancel any obligation
incurred under this payback agreement.

IV. TERMINATION NOTICE – ANNUAL REPORT
OF EMPLOYMENT – CHANGE OF ADDRESS
AND/OR NAME
I agree to complete and submit a Termination Notice (PHS
416-7) immediately upon completion of Kirschstein-NRSA
support. Thereafter, on an annual basis I agree to
complete and submit Annual Payback Activities
Certification forms sent to me by the awarding Federal

PHS 6031 (Rev. 06/12) Page 2

The completed form should be m ailed to the awarding
Federal Agency Grants Management Office named in the
Notice of Award.

NIH estimates that it will take 5 minutes to complete this form. This
includes time for reviewing the instructions, gathering needed
information, and completing and reviewing the form. An agency may not
conduct or sponsor, and a per son is not required to respond to, a
collection of information unless it displays a currently valid OMB control
number. If you have comments regarding this burden estimate or any
other aspect of this burden, send comments to: NIH, Project Clearance
Office, 6705 R ockledge Drive MSC 7974, Bethesda, MD 20892-7974,
ATTN: PRA (0925-0001). DO NOT RETURN THE COMPLETED FORM
TO THIS ADDRESS.

Nine Digit Social Security No. (Required):
Name (Last, first,
middle):
Signature:

-

-

Date:

Support received under the awarding
Federal agency Award/Grant Number:
Mailing Address:

E-mail:

Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by
the Privacy Act: NIH 09-25-0036, Extramural Awards and Chartered Advisory Committees (IMPAC 2), Contract
Information (DCIS), and Cooperative Agreement Information, HHS/NIH: http://oma.od.nih.gov/ms/privacy/pafiles/0036.htm.

PHS 6031 (Rev. 06/12) Page 3