Form 1 S2S LRP - Verification of Disadvantaged Background

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 Disadvantaged Background

(For School Use Only – Must be completed by a Financial Aid Official)

Name of Student (First, Middle initial, Last) Last 4 Digits of the Applicant’s SSN

Students from a disadvantaged background have either participated in or would have been eligible to participate in Federal programs such as “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, skill, and abilities required to enroll in and graduate from a school. Examples for environmental factors may include:

   1. Person that attended a high school with low average SAT/ACT scores or below the average State test results.

   2. Person from a school district where 50 percent or less of graduates go to college.

   3. Person who has a diagnosed physical or mental impairment that substantially limits participation in educational experiences.

   4. Person for whom English is not his/her primary language and for whom language is still a barrier to academic performance.

   5. Person who is the first generation to attend college.

   6. Person from a high school where at least 30 percent of enrolled students are eligible for free or reduced-price lunches.

2. Come from a family with an annual income below a level based on low-income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services (HHS) for adaptation to this program. For purposes of this program, annual income may not exceed 200 percent of the HHS poverty guidelines.

The Financial Aid Officer identified below certifies that the above-named student:

• Is from a disadvantaged background.

• Is NOT from a disadvantaged background.

Signature Printed Name Date

Title Phone Email

Name of School