Form 1 S2S LRP - Receipt of Exceptional Financial Need Scholars

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 Exceptional Financial Need (EFN)

(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 section 758 of the Public Health Service Act and qualify for a funding priority (applicable to medical students only).

Signature Printed Name Date

Title Phone Email

Name of School