1 Applicant Information

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Loan Repayment Programs
866-849-4047 | [email protected]

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

Applicant Information

NIH 2674-1
LRP Tracking Code:

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

Other Names
Used:
(e.g. Maiden)

First

Middle

Last

Suffix

First

Middle 

Last

Suffix 

Social Security Number:

SSN1

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.

SSN2 SSN3

NIH Commons ID:

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

US

Non-US

Address One:
Address Two:
State
State

City

State

Zip Code

+4

 Telephone Number:

Area

Exchange

Number

(Area code required)

Fax Number:
(optional)

Area

Exchange

Number

(Area code required)

Email:
(optional)

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

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

Assistant
Director
Assistant
Director

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

US

Non-US

Address One:
Address Two:
State
State

City

Telephone Number:

State

Area

Exchange

Number Ext

(Area code required)

Alternate Contact Number:
(optional) 

Area

Exchange

Number Ext

(Area code required)
Cell

Fax Number:

Pager

-

-

Zip Code

+4

Area

Exchange

Number

(Area code required)

Email Address:
Please communicate with me
at my:

Permanent (Home) or 

Current (Work or School) Address.

Section 4. Education and Training
Please attach your Biosketch:

Attach File:

no file selected

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.

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. 

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

Year:
Year
Year

Degree:
Degree
Degree
Major/Field of Specialization:
Conferring Institution:

Medical/Dental

Year:
Year
Year

Degree:
Degree
Degree

NOTE: If MD/Ph.D. complete information 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
SelectaaSpecialty
Specialty
Allergy
Allergyand
andImmunology
Immunology
- Clinical and Laboratory Immunology
- Clinical and Laboratory Immunology
Anesthesiology
-Anesthesiology
Pediatrics Anesthesiology
Pediatrics
--Critical
CareAnesthesiology
Medicine
Critical
Care Medicine
- Pain Management
- Painand
Management
Colon
Rectal Surgery

Colon and Rectal Surgery
Board Eligible

Yes

No

Board Certified
Yes No
Subspecialty:
(optional)

Select
SelectaaSpecialty
Specialty
Allergy
Allergyand
andImmunology
Immunology
- Clinical and Laboratory Immunology
- Clinical and Laboratory Immunology
Anesthesiology
-Anesthesiology
Pediatrics Anesthesiology
Pediatrics
--Critical
CareAnesthesiology
Medicine
Critical
Care Medicine
--Pain
Management
- Painand
Management
Colon
Rectal Surgery

Colon and Rectal Surgery
Board Eligible
Yes No
Board Certified
Yes No

Highest Graduate Degree (1):

Year:
Year
Year

Degree:
Degree
Degree
Major/Field of Specialization:
Conferring Institution:

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

Graduate Degree (2):

Year:
Year
Year

Degree:
Degree
Degree
Major/Field of Specialization:
Conferring Institution:

Graduate Degree (3):

Year:
Year
Year

Degree:
Degree
Degree
Major/Field of Specialization:

*Text hidden if intramural
Section 5. Federal Government Employment

Conferring Institution:

Are you employed for more
than 20 hours per week (5/8 or
greater) by a US Government
agency such as the NIH, CDC,
DOD, or the Veteran's
Administration? 

Are you currently on a
fellowship supported in whole
or in part by a US Government
agency such as the Veteran's
Administration, CDC, or DOD?

Yes (Please provide an explanation below)

No

Yes (Please provide an explanation below)

No

Please answer "No" if you are
supported by a National
Research Service
Award(NRSA) Fellowship (
T32/F32 ) through the NIH.
Section 6. Service Obligation
Note: If you have a service obligation, you may still be eligible for LRP consideration if your service obligation has been
or can be deferred for the entire period of your LRP contract. For assistance, please call the LRP Helpline at 1-866-8494047. Click here for examples of service obligations.
Do you owe a service payback obligation?

Yes (Continue with questions below)
No (Skip to Section 7)

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

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

Day

Year

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

Female

Male

Are you Hispanic or Latino?
Yes

No

Definition: 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.”

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

Definition of Category
American Indian or Alaska Native 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
Asian
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.
Native Hawaiian or Other Pacific A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
Islander
A person having origins in any of the black racial groups
Black or African American
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
White
Europe, the Middle East, or North Africa.
Do Not Wish to Provide

Disability Status:

Select Disability Code

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

Date of Birth:
Month

Day

Year

Section 8. Certifications
Certification of Nondelinquent Status
Applicants to the NIH Loan Repayment Programs who have a history of not honoring prior legal obligations or financial
responsibilities may not be eligible for the program.  Please provide us with the following certifications:
Do you have or have you ever had a judgment lien arising from a federal debt?
Yes

No

Have you ever defaulted on any educational debt/loan(s) or are you delinquent (more than 90 days past due) on any educational
loan?
Yes

No

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 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

Cancel

Save and Continue Later

Submit Form

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 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 2674-1
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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X
LRP Tracking Code: Click here to see the burden statement

NIH 2674-2

Personal Statement

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

Attach File:
no file selected

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

Cancel

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 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 2674-2
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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form
Approved
for
use through X/X/X
NIH 2674-3
Click
here
to
see
the
burden
statement
LRP Tracking Code:

Recommendations

Supervisor

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.
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 - Mentor
Instructions: Please identify the person who most recently served as your mentor as Recommender 1.
Recommender # 1
Name:
First

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

Section 2 - Required Recommendations
Recommender # 2
Name:

Middle

Last

Suffix

First

Middle

Last

Suffix

First

Middle

Last

Suffix

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

Recommender # 3
Name:

Email Address:
In what capacity do you know
the recommender?
Section 3 - 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

Last

Suffix

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 4 - Release and Waiver
Release to Contact Recommenders
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 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
By checking this box, I understand that I will not have access to the recommendations based on the promise of confidentiality
made to my recommenders in Section 3.
Cancel

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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X
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 .  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.  Click here for information on faxing financial documents .
Section 1 - Loan Information
Loan Account
Number:
Instructions: Please select your lender from the list below. If your lender is not included in the list, please
select "Other" and fill in the necessary information. You may also edit the address information that appears
for the lenders.
Name of Lending
Institution/Servicing
Agent:

Select
Lender
Select
Lender

Other:

Address One:

Address Two:
State
State

City

Name of servicing
agent of the loan
to whom payments
are sent (if

State

Zip Code

+4

different):
 Address One:

 Address Two:
State
State

City

State

Zip Code

+4

Section 2 - Loan Details
Original Amount of
Loan:

$

Date When Loan
was Disbursed:
Month

Monthly Payment
Amount:

Payoff Balance:
Payoff valid
through what
date?

Loan details
accurate as of
what date?

Year

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

$

$

Month

Current Interest
Rate of Loan:
Interest Type:

Day

Day

Year

%
Select
Interest
Type
Select
Interest

Type

Month

Day

Year

Section 3 - Loan Deferment Information
Loan Deferment:

Repayment (If selected, please proceed to next section)
Forbearance
Deferment/Grace

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

Start date of
current period:
Month

Day

Year

Month

Day

Year

End date of
current period:

Interest Bearing?

Yes
No

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

Yes
No

Are your payments
up to date?

Yes (or Not Applicable)
No

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? 
Date Loan
Repayment
Started:

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.

Yes
No (or Not Applicable)

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

Yes
No

Month

Day

Year

Purpose of Loan:
Type of Loan:

Select
Type
of Loan
Select
Type
of Loan

Section 5 - Certification by Applicant/Borrower

 Other:

I hereby apply to enter into an agreement with the Secretary of HHS for repayment of the educational loan listed above,
incurred solely for the costs of education, 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.

Cancel

Save and Continue Later

Submit Form

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 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 2674-4
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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

Research Activities

NIH 2674-6
LRP Tracking Code:

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

Section 1 - Research Activities
Note: Your Research Supervisor/Mentor is identified on the Recommendation Form under Recommender #1 (Supervisor).
Please ensure that you have completed and submitted that form before submitting this form. Your Research Supervisor/Mentor
will not receive the email requesting that they complete their form until both the Recommendation and Research Activities forms
are submitted.
When you press submit this form will lock and an email will be sent to your Research Supervisor/Mentor to request that (s)he
complete the online forms. Hidden if applicant did not identify Research Supervisor
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:

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

Shortened/General
Title:

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

Please attach your
research activities
description:

Attach File 

no file selected

Instructions: Click the "Browse" button
and locate your file. We accept most
word processing formats. Please note: If
your file is over 5 MB, then you should
create a PDF and then upload it.

Section 2 - 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 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 

no file selected

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

Section 3 - Career Development Plan
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 

no file selected

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

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 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 2674-6
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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

Basic Information
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

Non-US

Address One:
Address Two:
State
State

City

Telephone Number:
(including area
code)

State

Area

Zip Code

+4

Exchange

Number Ext

(Area code required)

Fax Number:
(including area
code)

Area

Exchange

Number

(Area code required)

Cancel

Privacy Act 09-25-0165

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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

Research Accomplishments

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

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. It is important to list your research publications in your biosketch
uploaded on the Applicant Information form (see biosketch instructions for details).
Note: Your Principal Investigator/Research Supervisor will be asked to concur with your statement and to provide their
assessment of your research accomplishments. Your Principal Investigator/Research Supervisor will NOT have access to
complete their online forms until you submit this form.

Click here if you have recently moved to a new laboratory and a different individual (not your current Research Supervisor) can
better 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.

Attach File: 

Please attach your description of
your research accomplishments:

*Text hidden if box is not checked

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

Cancel

Save and Continue Later

Submit

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.
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 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 2674-8
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.

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866-849-4047 | [email protected]

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

Certifications for Online Applications

NIH 2674-9
LRP Tracking Code:

Instructions: Please print this form and sign it (black ink preferred). The form can either be uploaded using the upload feature on
Print
Continue
the Application Status page or it can be faxed without a cover page to 1-866-849-4046.
Section 1 - Certification by Applicant/Borrower
I hereby apply to enter into an agreement with the Secretary of HHS for repayment of the educational loan listed in my application, incurred
solely for the costs of education, including reasonable living expenses. I hereby certify that the information given in this application is true,
complete, and accurate to the best of my knowledge and does not omit any material fact that would render the statement false, fictitious, or
fraudulent as a result of the omission. I am aware that any false, fraudulent, or fictitious statement may, in addition to other remedies available
to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986. I hereby authorize the lending
institution, servicing agent, and/or institutional program named in my application to release information about my loan or any loan owned,
serviced, or administered by my lending institution, servicing agent, or program administrator to the administrators of the NIH Loan Repayment
Programs (LRP) and other authorized Government officials. This authorization shall remain in effect during my application and participation in
the NIH LRP and 120 days after completion of LRP contracted service.
____________________________________________________
Signature (sign your full name in ink)

_____________________
Date

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

_____________________
Date

Section 3 - Applicant's Request for Confidential Recommendations
I certify that I am requesting recommendation(s) from individual(s) of my choosing that will be included in my NIH Loan Repayment Program
(LRP) application. My application, including the completed recommendation forms submitted by my recommenders, will be used by NIH
officials to determine my eligibility for participation in an LRP. I understand that the recommendation(s) I am requesting shall be held in
confidence and protected from disclosure by officials of the NIH Loan Repayment Programs according to Privacy Act System of Records #0925-0165 (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

LRP Tracking Code:
Public reporting for this collection of information is estimated to average 20 minutes, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information, unless is displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974,
Attention: PRA 0925-0361. Do not return the completed form to this address.
NIH Form 2674-9
Privacy Act 09-25-0165

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X
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 the option to provide
an assurance of one or two years of continuing support and a minimum 50% commitment (20 hours per week) of research effort.
Please ensure that all email addresses are entered accurately as once you press SUBMIT you cannot return to this form to make
changes.
Important: The official providing this information should be someone authorized to reply for the organization. Common titles for
this individual are dean, associate dean, provost or chancellor of research & sponsored programs, or vice president of research
administration. If you are not certain whom to name, please consult with your research supervisor or principal investigator.
Note: Several Institutions have provided us with the proper contact for this certification. You may use the list below to check for
your institution. If you select one of the organizations from the list, the system will automatically update the contact information for
you. You will be allowed to change the information, if needed. If you do not see your institution listed, please enter the Name and
Email address of your contact.
Contact Information for the Institutional Representative
Organization:
Name:
First

Middle

Last

Suffix

Email Address:

Cancel

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 2674-10
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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

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

Disadvantaged Background

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. 

I have received a loan from the Health Professions Student Loans (HPSL) or Loans for
Disadvantaged Student Program.

(1) 

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

(3)

Important: You must submit this documentation to the NIH Division of Loan Repayment Programs for
your application to be complete. You may either upload the documentation using the upload feature
on the Application Status page or you may fax it. Your application cannot be considered without this
documentation.
Cancel

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 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 2674-11
Privacy Act 09-25-0165

Please periodically click SAVE & CONTINUE in order to not lose

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

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 $10,000 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 11-2010

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 11-2010

Privacy Act 09-25-0165

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

Basic Information
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

Non-US

Address One:
Address Two:
0State

City

Telephone Number:
(including area
code)

State

Area

Zip Code

+4

Exchange

Number Ext

(Area code required)

Fax Number:
(including area
code)

Area

Exchange

Number

(Area code required)

Cancel

Privacy Act 09-25-0165

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.

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

Basic Information
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

Non-US

Address One:
Address Two:
0State

City

Telephone Number:
(including area
code)

State

Area

Zip Code

+4

Exchange

Number Ext

(Area code required)

Fax Number:
(including area
code)

Area

Exchange

Number

(Area code required)

Cancel

Privacy Act 09-25-0165

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.

U.S. Department of Health & Human Services

National Institutes of Health

Office of Extramural Research

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

About the Programs

Apply Here

Log In

Contact Us
OMB No. 0925-0361
Form Approved for use through X/X/X
Click here to see the burden statement

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:

SSN1

SSN2 SSN3

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.

Already have a password? Click here to log in!
Forgot your password?  Click here to recover your password!
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

Glossary | Accessibility | FOIA | Disclaimer | Privacy Policies

U.S. Department of Health & Human Services

National Institutes of Health

Skip Navigation

Office of Extramural Research

Loan Repayment Programs
866-849-4047 | [email protected]

About the Programs

Apply Here

Log In

Contact Us

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:
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 (~!@#$%^&*())

Create Password:
Reenter Password:

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!

Glossary | Accessibility | FOIA | Disclaimer | Privacy Policies
Note that this site uses cookies, Click Here for more Information

Download Readers

QUESTIONS? LRP INFORMATION CENTER | MON-FRI, 9:00 AM - 5:00 PM EST | 866 - 849 - 4047 | [email protected]
Date Last Updated: February 23, 2013 | Date Last Reviewed: February 23, 2013

U.S. Department of Health & Human Services

National Institutes of Health

Skip Navigation

Office of Extramural Research

Loan Repayment Programs
866-849-4047 | [email protected]

About the Programs

Apply Here

Log In

Contact Us

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 forms 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.

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.

Glossary | Accessibility | FOIA | Disclaimer | Privacy Policies
Note that this site uses cookies, Click Here for more Information

Download Readers

QUESTIONS? LRP INFORMATION CENTER | MON-FRI, 9:00 AM - 5:00 PM EST | 866 - 849 - 4047 | [email protected]
Date Last Updated: February 23, 2013 | Date Last Reviewed: February 23, 2013

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

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
Extramural

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

Save and Continue

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.

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Loan Repayment Programs
866-849-4047 | [email protected]

Step 2 of 2: Questions for Extramural Applicants

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.)

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.

Contraception
and Infertility
Research LRP
Health
Disparities LRP

Added if Renewal:
Renewal Length: Please select one or two year renewal

One year renewal
Two year renewal

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Privacy Act 09-25-0165

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time period.

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Loan Repayment Programs
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Step 2 of 2: Questions for Intramural Applicants
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:

SelectTitle
Title
Select

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

Month

Day

Year

SelectInstitute
Institute
or Center
Select
or Center
(IC) (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. Click here to visit US Bureau of
Citizenship & Immigration Services.
 Citizenship:

U.S. Citizen or Non-Citizen National of the U.S.
U.S. Permanent Resident

Country of
Citizenship:
Alien Registration #:

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Privacy Act 09-25-0165

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NATIONAL INSTITUTES OF HEALTH

NIH LOAN REPAYMENT PROGRAMS / LOAN INFORMATION FORM
OMB No. 0925-0361
Form Approved For Use Through X/X/X

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

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

Verification of
U.S. Citizenship
or
Permanent
Residency Status

NIH 2674-18
Name:
LRP Tracking Code:

Instructions: Please print, complete, and sign this form (black ink preferred). The form and the documents
verifying your citizenship status can either be uploaded using the upload feature on the Application Status page
or faxed to 1-866-849-4046.

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://uscis.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 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

Skip Navigation

Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X
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 listing grants, please include the total value of the grant not just your portion. 
This is not intended to provide information on what source is supporting you directly (i.e. your salary). Salary is only appropriate if
you have no other source of funding. For example: if your non-profit employer is the sole source of your research funding, then
list your non-profit employer in Section 1 and select "salary" or "Institutional Start Up funds" for the funding category.
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 (non-NIH grant).  List up to three non-profit or government funding sources in descending order of funding amount. Only
include your non-profit employer if your non-profit employer is your only non-profit funding source. If funding will start in the future
list the anticipated date of funding as the start date. Only list grant support from the NIH in Section 3 and National Research
Service Awards (NRSA) Fellowships support in Section 2.
Non-Profit Funding Source #1
Name of Funding
Organization:
(150 character limit)

Title of Grant/Award:

(1000 character limit)

Amount of Funding:
 $US

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

Funding Category

Award Status
Are you the PI on this
Grant?

Salary Non-Profit Organization Grant
Federal Grant (non-NIH)
Pending Review
Yes

Awarded

Institutional Start up Funds

State/Local Govt Grant

Salary

No

Start of Funding:

End of Funding:
Month

Day

Year

Month

Day

Year

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

Title of Grant/Award:

(1000 character limit)

Amount of Funding:
 $US

Funding Category

Award Status
Are you the PI on this
Grant

Salary Non-Profit Organization Grant
Federal Grant (non-NIH)
Pending Review
Yes

Awarded

Institutional Start up Funds

State/Local Govt Grant

Salary

No

Start of Funding:

End of Funding:
Month

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

Title of Grant/Award:

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

Day

Year

Month

Day

Year

(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 

Salary Non-Profit Organization Grant
Federal Grant (non-NIH)
Pending Review
Yes

Awarded

Institutional Start up Funds

State/Local Govt Grant

Salary

No

Start of Funding:

End of Funding:
Month

Day

Year

Month

Day

Year

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

App

Type

IC

Number

  (Example: 1 T32 CA 811009 - 01)
YR

(Not all NIH award number fields are required)

Award Status

Pending Review

Awarded

Start Date for First Year
of Training Grant:

Length of Funding:
Month

Day

 (months)

Year

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

NIH Grant/Award
Number (Project
Number):

App

Type

IC

Number

  (Example: 1 K08 CA 811009 - 01 A1S1)
YR

Desc

(Not all NIH grant number fields are required)

Title of Grant/Award:

(1000 character limit)

Amount of Funding:

Award Status

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

Pending Review

Awarded

Start of Funding:

End of Funding:
Month

Day

Year

Month

Day

Year

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

App

Type

IC

Number

  (Example: 1 K08 CA 811009 - 01 A1S1)
YR

Desc

(Not all NIH grant number fields are required)

Title of Grant/Award:

(1000 character limit)

Amount of Funding:

Award Status< TD>

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

Pending Review

Awarded

Start of Funding:

End of Funding:
Month

Day

Year

Month

Day

Year

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

  (Example: 1 K08 CA 811009 - 01 A1S1)

App

Type

IC

Number

YR

Desc

(Not all NIH grant number fields are required)

Title of Grant/Award:

(1000 character limit)

Amount of Funding:

Award Status

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

Pending Review

Awarded

Start of Funding:

End of Funding:
Month

Day

Year

Month

Cancel

Day

Year

Save and Continue Later

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

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.