D Attachment D-Graduation Close Out Form

DEPARTMENT OF HEALTH & HUMAN SERVICES Health Resources and Services Administration

Bureau of Clinician Recruitment and Service Rockville, Maryland 20857

Nurse Corps Scholarship Program

Graduation/Close out Documentation

*TO BE COMPLETED BY THIRD PARTY BILLING REPRESENTATIVE*

1. Date____________________________________________________________________

2. Name of Participant_______________________________________________________

3. Institution_______________________________________________________________

4. Last Four SSN ___________________________________________________________

5. Graduation Date __________________________________________________________

6. NCSP Balance Owed? Yes______ No______

• If Yes, what is the Balance? __________________________________________

• I have attached copy of invoice. Yes______ No______

School Stamp/Seal

School Representative Signature Date

________________________________ ________