Form 13 Certification Form

Last Updated – February 21, 2013

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

Undergraduate Scholarship Program (UGSP) / National Institutes of Health (NIH)
U.S. Department of Health and Human Services (DHHS)
Undergraduate Institution Certification for Exceptional Financial Need (EFN)
Applicant’s Instructions – Please complete Section A. Undergraduate Institution’s Instructions – Please complete Section B and return the
Give this form to the financial aid office at the school at
form by mail to National Institutes of Health Undergraduate Scholarship Program, 2
which you are enrolled or will be enrolled starting
Center Drive / Room 2W11A (MSC 0230), Bethesda, Maryland 20892-0230. Or fax to
September 2013. NOTE: FAFSA information used to
301-480-5481. If you have any questions, call 301-402-3831 or e-mail .
complete this form must be taken from 2012 taxes.
Section A – The applicant completes this section. Items 1 through 3 may be completed before printing.
1. Applicant’s Name (last, first, middle)
1a. Other Names Used on Official Documents (last, first, middle)
2. Student Identification Number
3. Email Address Used for Your UGSP Application
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
-Is this student accepted for enrollment or expected to be enrolled as a full-time student for the 2013-2014 academic year? ¨yes ¨ no
-If currently enrolled, is this student in good standing? ¨yes ¨ no
-What is the anticipated graduation date for this student? ________________________________________________________________________
2. Exceptional Financial Need Status –
-Does this student qualify for EFN for the 2013-2014 academic year (see page 2 for definition): ¨yes ¨ no
NOTE: FAFSA information used to complete this form must be taken from 2012 taxes.
3. Addition Sources of Financial Support – The above
4. Calculation of Eligible Tuition, Education and Living Expenses for 2013-2014
named student (Section A) has been awarded the
– The UGSP scholarship covers up to $20,000.00 per academic year toward (1)
following financial aid for 2013-2014 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 burden for this collection of information is estimated to average 15-minutes per response, including the time for reviewing instructions. 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.

NIH 2762-3

Last Updated – February 21, 2013

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

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 lowincome 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
Academic Year
Fall 2013 – Spring 2014
Persons in Family
Family Income Level
(Includes only dependents listed
(Adjusted gross income,
on Federal income tax forms)
rounded to the nearest $100)
1
$22,340.00
2
$30,260.00
3
$38,180.00
4
$46,100.00
5
$54,020.00
6
$61,940.00
7
$69,860.00
8
$77,780.00
For families with more then 8 persons, add $7,920.00 for each
additional person
Federal Register, V77, N74, P22790, Tuesday, April 17, 2012.
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The primary use of information collected via the Office of Intramural Training and Education (OITE) online forms is to evaluate an applicant's
qualifications for research training at the National Institutes of Health (NIH). Information may be used during admission consideration; in preparing
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violations of law or regulation. Application for this program is voluntary, however, in order for the OITE to process an application, the applicant must
complete the required fields.
The legal authority granted to NIH to train future biomedical scientists comes from several sources. Title 42 of the U.S. Code, Sections 241 and
282(b)(13) authorize the Director, NIH, to conduct and support research training for which fellowship support is not provided under Part 487 of the
Public Health Service (PHS) Act (i.e., National Research Service Awards), and that is not residency training of physicians or other health
professionals. Sections 405(b)(1)(C) of the PHS Act and 42 U.S.C. Sections 284(b)(1)(C)] and 285-287 grant this same authority to the Director of
each of the Institutes/Centers at NIH.

NIH 2762-3