Form 6 UGSP Certification Exceptional Financial Need

Last Updated – August 20, 2015

Undergraduate Scholarship Program (UGSP)
Office of Intramural Training & Education (OITE)
National Institutes of Health (NIH)
Department of Health and Human Services (HHS)
2 Center Drive: Building 2 / Room 2E24
Bethesda, Maryland 20892-0230

OMB No. 0925-0299
Form approved for use through 08/31/2016

Fax: 301-594-9606
Email: [email protected]
Web: https://www.training.nih.gov/programs/ugsp

Dear UGSP Applicant,
We are pleased that you are considering submitting an application to the NIH Undergraduate Scholarship Program (UGSP) for
admission in Fall 2016. Applicants to the UGSP must fulfill the following eligibility requirements:
• United States citizen or United States permanent resident
• Enrolled or accepted for enrollment as a full-time student at an accredited 4-year undergraduate institution located in the
United States of America
• Undergraduate Grade Point Average (GPA) of 3.3 or higher on a 4.0 scale or within the top 5 percent of your class
• Having Exceptional Financial Need (EFN) as certified by your undergraduate institution financial aid office (see page-3)
If you meet the first three requirements listed above, please complete questions 1 through 3 in Section-A of the Exceptional
Financial Need (EFN) form prior to printing to ensure clarity for university and UGSP staff. Take this entire document to your
academic institution’s financial aid office to confirm your EFN status. If you are transferring to another institution/university, send
this form to the institution where you will be enrolling. Once submitted, begin your application for Fall 2016 admission;
application form opens on January 4, 2016. You may save a partial application and return to complete at a later time.
Dear Financial Aid Officer,
The Undergraduate Institution’s Financial Aid Office must complete all questions within Section-B. Please take care to make
sure question 2 (Exceptional Financial Need Status) is completed; else we cannot accept the EFN form and the student will
receive an automatic rejection letter. If tax information from 2015 is unavailable at the time of receiving this request, you are
welcome to complete the form using tax information from 2014 (see question 2 sample provided below). We will make a special
note in the applicant’s file that the EFN form will need to be resubmitted with 2015-tax information in order to receive full
consideration for this scholarship.

Should you have any questions or concerns about eligibility or completing the EFN form, please contact Mr. Adrian Warren
([email protected] or 301-402-3831) at your earliest convenience.
Best regards,
Darryl Murray, PhD
Director, UGSP
Email: [email protected]
Phone: 301-594-2222

NIH 2762-3

Last Updated – August 20, 2015

OMB No. 0925-0299
Form approved for use through 08/31/2016

Undergraduate Institution Certification for Exceptional Financial Need (EFN)
Undergraduate Scholarship Program (UGSP) / National Institutes of Health (NIH) / U.S. Department of Health and Human Services (DHHS)
Applicant’s Instructions – Complete Section A. Give Undergraduate Institution’s Instructions – Complete Section B and return by March 14, 2016
this form to the financial aid office at the 4-year college either by fax (301-594-9606) or mail to:
NIH Undergraduate Scholarship Program
/ university at which you are enrolled or will be enrolled
2 Center Drive / Room 2W11A
in Fall 2016. NOTE: FAFSA information used to
Bethesda, Maryland 20892-0230
complete this form must be taken from 2015 taxes.
Questions: call Mr. Adrian Warren at 301-402-3831 or e-mail [email protected].
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. University 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 six-months
after the UGSP application deadline.
Signature (Sign your full name in ink)______________________________________________________________ Date______________________
SECTION B – The Undergraduate Institution Financial Aid Office must complete questions 1 through 6 before sending to the NIH UGSP.
~ ATTENTION: The UGSP will not accept this form unless Question-2 is completed, resulting in an automatic rejection letter to the student. ~
1. REQUIRED: Enrollment Status
-Is this student enrolled or accepted for enrollment as a full-time student for the 2016-2017 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. REQUIRED: Exceptional Financial Need Status – FAFSA information used to complete this form must be from 2015 OR 2014 tax information.
-Does this student meet the threshold for EFN status, see page 2 for definition, for the 2016-2017 academic year based on 2015-tax information?:
! yes (go to question 3)
! no (go to question 6)
! unknown because 2015 tax information is unavailable
-Does this student meet the threshold for EFN status, see page 2 for definition, for the 2016-2017 academic year based on 2014-tax information?:
! yes
! no
(Note: Using 2014-tax information means this student will need to resubmit this form when 2015 tax information becomes available.)
3. REQUIRED: Calculation of Eligible Tuition, Education and Living Expenses for
4. REQUIRED: Addition Sources of Financial Support –
2016-2017 The UGSP scholarship covers up to $20,000.00 per academic year toward (1)
The above named student (Section A) has been awarded
tuition, (2) reasonable education expenses, and (3) reasonable living expenses.
the following financial aid for 2016-2017 academic year:
-Tuition: What is the tuition amount for this student?
$________________Tuition
$________________Student Loans
-Educational Expenses: What are the average educational expenses for the categories
$________________Institutional Scholarships
listed below?
$________________Non-Institutional Scholarships / Grants
$________________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
5. REQUIRED: Unmet Financial Need
$________________Transportation
Total Expenses minus Total Financial Support
$________________Total Expenses (Tuition + Education + Living Expenses)

$________________Unmet Financial Need

6. REQUIRED: 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 ________________________________________________________________________________________________________
University’s 9 Digit DUNS (Data Universal Numbering System) Number: ____________________________________________________________
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 – August 20, 2015

OMB No. 0925-0299
Form approved for use through 08/31/2016

Instructions for Undergraduate Institution Certification Form NIH 2762-3
Exceptional Financial Need Status Identification of Individuals from Disadvantaged Backgrounds (Scholarship applicants must be from disadvantaged
backgrounds)
A student from a disadvantaged background is one who comes from a family with an annual adjusted gross income below a level based on low-income
thresholds according to family size, as published by the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and
adjusted by the Secretary, DHHS, for use in all health professions programs.
Qualification of EFN Status. Applicants who qualify as having EFN status must provide the Financial Aid Director of their undergraduate institution total
financial information, including: parent’s income and spouse’s income (if applicable), regardless of the student’s taxable status, and must be of EFN, as
defined by the Secretary, DHHS, (see above). The Financial Aid Director must certify this information and the institution’s certification of an applicant’s
EFN status must be included with the UGSP application package.
The Secretary, DHHS, will periodically publish these low-income levels in the Federal Register. (Please see the table below for the most recent
determination of low-income levels). If family income for the most recent calendar year is less than the income level indicated on the chart below for the
appropriate family size, students fulfill the definition of an individual having exceptional financial need (EFN). Students certified as being of EFN are
considered to be from disadvantaged backgrounds.
Low-Income Levels—Secretary DHHS (48 contiguous states and District of Columbia)
Federal Register: Vol. 80; Thursday, January 22, 2015.
2015 Poverty Guidelines for the NIH Undergraduate Scholarship Program (UGSP)
Persons in Family
(Includes Only Dependents Listed on Federal Income Tax Forms)
1
2
3
4
5
6
7
8
More than 8 Persons

Family Income Level
(Adjusted Gross Income)
$23,540
$31,860
$40,180
$48,500
$56,820
$65,140
$73,460
$81,780
$8,320.00 for Each Additional Person

Privacy Act Notice
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 appointment
paperwork; and to provide data for training program evaluation. Information will be disclosed to investigators, members of advisory committees, OITE
staff, and contractors working on our behalf. Additional disclosures may be made to law enforcement agencies concerning 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