Form 5 Verification of Disadvantaged Background Form

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM
VERIFICATION REGARDING DISADVANTAGED BACKGROUND
For School Use Only – Must be completed by Financial Aid Official. Once completed, please return to the NHSC LRP applicant for
submission with their program application.

Student’s Name

Last 4 digits SSN

The Financial Aid Official identified below certifies that the above-named student (check one below)

is

is NOT

from a disadvantaged background (criteria described below). Students from a disadvantaged background have either participated
in or would have been eligible to participate in Federal Programs such as the “Scholarships for Disadvantaged Students,” “Loans to
Disadvantaged Students,” or the “Nursing Workforce Diversity Grant Program.”
CRITERIA FOR DISADVANTAGED BACKGROUND STATUS:
1. Come from an environment that has inhibited them from obtaining the knowledge, skills, and abilities required
to enroll in and graduate from a health professions or nursing school (Environmentally Disadvantaged). The
following are provided as examples of “Environmentally Disadvantages” for guidance only and are not intended
to be all-inclusive.
Examples:
• Person from high school with low average SAT/ACT scores or below the average State test results.
• Person from a school district where 50 percent or less of graduates go to college.
• Person who has a diagnosed physical or mental impairment that substantially limits participation in educational
experiences.
• Person for who English is not his or her primary language and for whom language is still a barrier to academic
performance.
• Person who is first generation to attend college.
• Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced price
lunches.
– OR –
2. Come from a family with an annual income below a level based on low-income thresholds established by the U.S. Census
Bureau, adjusted annually for changes in the Consumer Price Index (Economically Disadvantaged).
The Secretary defines a ‘‘low income family’’ for various health professions and nursing programs included in Titles III,
VII and VIII of the Public Health Service Act as having an annual income that does not exceed 200 percent of the
Department’s poverty guidelines. A family is a group of two or more individuals related by birth, marriage, or adoption
who live together or an individual who is not living with any relatives.
FINANCIAL AID OFFICIAL:
Signature

Date

Printed Name

Phone Number

Email Address

Name of School

Applicant: Scan and upload this document to your NHSC LRP application prior to submitting your NHSC LRP application. You can
access your application via the Customer Service Portal, at https://programportal.hrsa.gov/extranet/landing.seam.