Form 1 S2S LRP – Acceptance/Verification of Good Standing Repor

Bureau of Clinician Recruitment and Service

U.S. Department of Health and Human Services

Health Resources and Services Administration

National Health Service Corps Students to Service Loan Repayment Program

Verification of Good Standing

(To be completed by a school official only)

The Verification of Good Standing report certifies that the student identified below is enrolled and in good standing for the 2013-14 academic year as indicated. Please note that all information will be verified for accuracy.

1. Student’s Name (First, Middle Initial, Last): _______________________________

2. Student’s SSN (Last 4 digits): _______________­­­__­­­­­­­­­­­­­­­ ____________________________

3. What program is the student currently enrolled in: ­­­­­­­­­­­­­­­­­­­­­­­­­_____________________________________________

4. Is the student in good standing? (If NO, please explain): ­­­­­­­­­­­­­­­­­­­­­­­­­_________________________________________

5. Degree the student will receive upon completion of the program: _________________________________

6. Is the student in their final year of the program: Yes No

7. When will the all course work and rotations be completed? ­­­­­­­­­­­­­­­­­­­­­­­­­______________________________________

8. Anticipated date of graduation (mm/yyyy):­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­____________________________________________________

By signing my name below, I certify that the current status of the student listed above has been correctly identified. I further certify that, where necessary, I have corrected the “Year in Program” and “Date of Graduation” for the student to accurately reflect the anticipated graduation date given the current enrollment. I understand that any willfully false information may be punishable as a felony under U.S. Code, Title 18, Section 1001.

Signature Printed Name Date

Title Phone Email

Name of School