Form 1 FY 2017 NHSC SP Verification of Exceptional Financial Ne

Bureau of Health Workforce

U.S. Department of Health and Human Services Health Resources and Services Administration

OMB No.: 0915-0146

Expiration Date: XX/XX/20XX

National Health Service Corps Scholarship Program

Receipt of Exceptional Financial Need Scholarship

(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

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

□ has NOT received

a Scholarship for Students of Exceptional Financial Need (EFN) under former section 758 of the Public Health Service Act (applicable to medical and dental students only).

Signature Printed Name Date

Title Phone Email

Name of School

Student may upload signed form to the NHSC SP Online Application: https://programportal.hrsa.gov/

Public Burden Statement: 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. The OMB control number for this project is 0915–0146. Public reporting burden for this collection of information is estimated to average 0.25 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD 20857.