Form NSF 1715 NSF 1715 HSI Certification Form

HSI CERTIFICATION FORM
The lead institution submitting a proposal to the Hispanic-Serving
Institution Program (HSI Program) must be a Hispanic-serving institution
(HSI) as defined by law (http://legcounsel.house.gov/Comps/HEA65_CMD.pdf).
Check the box that applies.
My institution is an HSI certified by the United States Department
of Education (ED). A copy of the most recent Letter of
Eligibility from ED is uploaded as a supplementary document with
this proposal.
My institution is not on ED’s most recent Eligibility Matrix but is
an HSI as defined by law.

Certification of HSI. A Certification as an HSI, following the format
below and executed by an Authorized Organizational Representative, must
be included with the HSI Program proposal. A current, signed
Certification, on institutional letterhead, should be scanned and
included as a searchable PDF file in the proposal as Supplementary
Documentation.

Certification as an HSI
By submission of this proposal, the institution hereby certifies that
the originating and managing institution is a Hispanic-serving
institution of higher education, during the previous academic year.
Authorized Organizational Representative ....................................
Typed Name and Title ........................................................
Signature .........................................Date......................

---------------------------------------------------------------------*****************BELOW FOR INTERNAL USE ONLY*************************

HSI eligibility status has been verified per the H SI definition in section 502 of the H igher Education
Act of 1965 (20 U.S.C. 1101a) and/or Department of Education Eligibility Matrix as of
_____ / _____ / ___________.
(Initial) _________.

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HSI Certification Form 1715

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Definitions:
The terms below are defined in section 502 of the Higher Education Act of 1965 (20 U.S.C. 1101a)
found at: http://legcounsel.house.gov/Comps/HEA65_CMD.pdf
1. Hispanic-serving institution (HSI)
2. Full-time Equivalent

Reference:
1. The Higher Education Act of 1965 (P.L. 89-329) [As Amended Through Public Law 113–
67, Enacted December 26, 2013]; http://legcounsel.house.gov/Comps/HEA65_CMD.pdf

Note: The NSF does not restrict institutions with multiple designations (e.g. PBI, HBCU, ANNH)
from certification.
Public burden statement:
An agency may not conduct or sponsor, and a person is not required to respond to, an information
collection unless it displays a valid Office of Management and Budget (OMB) control number. The OMB
control number for this collection is 3145-XXXX. Public reporting burden for this collection of
information is estimated to average 2 minutes per response, including the time for reviewing
instructions.
Send comments regarding the burden estimate and any other aspect of this collection of information,
including suggestions for reducing
this burden, to:
Suzanne H. Plimpton
Reports Clearance Officer
Office of the General Counsel
National Science Foundation
Alexandria, VA 22314

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HSI Certification Form 1715

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