3 Institution Loan Repayment Form

Faculty Loan Repayment Program

Fiscal Year 2018 Supplemental Form

Institution Employment/Loan Repayment Verification Form

OMB No. 0915-0150 Expiration: TBD

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 current OMB control number. The information is being collected and will be used to evaluate an applicant’s eligibility, qualifications, and suitability for participating in the FLRP. Public reporting burden for this collection of information is estimated to average XXX hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Disclosure of information sought is voluntary; however, if not submitted, except for questions related to Race/Ethnicity on the online application, an application will be considered incomplete and therefore will not be considered for an award. The information applicant’s supply will be maintained in a system of records and subject to disclosure under the Privacy Act Notification Statement in the FLRP Application and Program Guidance. 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 Office, 5600 Fishers Lane, Room 14N39, Rockville, Maryland 20857.

Faculty Loan Repayment Program

OMB No. 0915-0150, Expiration: TBD

Institution Employment/Loan Repayment Verification Form

(To be completed by institution)

The (Institution – print or type) intends to employ (Applicant – print or type) in a faculty position (duties primarily consist of teaching in a classroom) for a minimum of 2 years. This employment must begin on or before June 28, 2018.

The position is (check one): full-time or part-time Number of hours/week: This is a tenured position (check one): Y N

Employment Start Date:

Employment End Date: Date Fall Term begins: Number of months in an academic year:

Number of months in an academic year individual serves as faculty:

School of (e.g., medicine, nursing, allied health)

The institution is accredited by

Employing Institution Type (choose one): ( ) private non-profit ( ) public/government owned ( ) private for profit

NOTE: The only programs eligible to be private, for-profit institutions and qualify for FLRP are nursing and physician assistant programs.

The institution (must check one)*:

Has agreed to make payments of principal and interest on the educational loans of the applicant in an amount equal to the amount of such payment(s) made by the HHS Secretary (maximum $40,000 total for 2-year contract period). These payments will be in addition to the applicant’s faculty salary and the applicant’s salary will be determined without regard to the amount paid by HHS/FLRP. A copy of the Loan Repayment Agreement must be attached.

Is unable to make any payments of principal and interest on the educational loans of the applicant and requests a full waiver, on the basis of undue financial hardship, of the requirement that the institution make loan repayments equal to the amount of such payment(s) made by the HHS Secretary. The school must attach a letter requesting a full waiver and supporting documentation of undue financial hardship, as specified in the FLRP Application and Program Guidance (APG), and submit this form, the letter and the supporting documentation to the

applicant for submission with the application.

Is able to make payments of principal and interest on the educational loans of the applicant in an amount less than the amount of such payment(s) made by the HHS Secretary (maximum $40,000 total for 2-year contract period) and requests a partial waiver, on the basis of undue financial hardship, of the requirement that it fully match the HHS Secretary’s payment(s). The school must attach a letter requesting a partial waiver and supporting documentation of undue financial hardship, as specified in the APG, and submit this form, the letter and the supporting documentation to the applicant for submission with the application. The school must also attach a copy of its Loan Repayment Agreement to partially match the amount paid by HHS/FLRP.

*Institutions who fail to comply with their specific match agreement indicated above will be held liable for default, and all future applicants employed at their institution will be deemed ineligible for the FLRP.

School Official’s Name Title

Signature Date

Mailing Address Phone/Fax/Email