Form 18 UGSP Certification

Last Updated – 31-August-2018

OMB Clearance Number: 0925-0299
Expiration Date: 30-June-2019

Undergraduate Scholarship Program (UGSP)
Office of Intramural Training & Education (OITE)
National Institutes of Health (NIH)
Department of Health and Human Services (HHS)
2 Center Drive: Building 2 / Room 2E24
Bethesda, Maryland 20892-0230

Fax: 301-594-9606
Email: [email protected]
Web: https://www.training.nih.gov/programs/ugsp

Dear UGSP Applicant,
We are pleased that you are considering submitting an application to the NIH Undergraduate Scholarship Program (UGSP) for
admission in Fall 2019. Applicants to the UGSP must fulfill the following eligibility requirements:
• United States citizen or United States permanent resident
• Enrolled or accepted for enrollment as a full-time student at an accredited 4-year undergraduate institution located in the
United States of America
• Undergraduate Grade Point Average (GPA) of 3.3 or higher on a 4.0 scale or within the top 5 percent of your class
• Having Exceptional Financial Need (EFN) as certified by your undergraduate institution financial aid office (see page-3)
If you meet the first three requirements listed above, please complete questions 1 through 3 in Section-A of the Exceptional
Financial Need (EFN) form prior to printing to ensure clarity for university and UGSP staff. Take all three pages of this document
to your academic institution’s financial aid office to confirm your EFN status. If you are transferring to another
institution/university, send this form to the institution where you will be enrolling Fall 2019. You can begin your UGSP application
for Fall 2019 admission when the application opens on January 2019. Please request that your financial aid office complete
section B of this form and return it to you. You must forward the completed form to our office by mail, fax, or email (see
header for address).
Dear Financial Aid Officer,
The Undergraduate Institution’s Financial Aid Office must complete all questions within Section-B. Please take care to make
sure question 2 (Exceptional Financial Need Status) is completed and the certification includes your institution’s seal or stamp.
Otherwise we cannot accept the EFN form and the student will receive an automatic rejection letter. Tax information from 2017
or 2018 may be used to complete this form. Please return the completed form to the student for submission.
Should you have any questions or concerns about eligibility or completing the EFN form, please contact Mr. Adrian Warren
([email protected] or 301-402-3831) at your earliest convenience.
Best regards,
Darryl Murray, PhD
Director, UGSP
Email: [email protected]
Phone: 301-594-2222

NIH 2762-3

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Last Updated – 31-August-2018

OMB Clearance Number: 0925-0299
Expiration Date: 30-June-2019

Undergraduate Institution Certification for Exceptional Financial Need (EFN)
Undergraduate Scholarship Program (UGSP)
National Institutes of Health (NIH)
U.S. Department of Health and Human Services (DHHS)
Applicant’s Instructions – Complete Section A. Give this form to the It is the responsibility of the applicant to return this form, completed, to the
financial aid office at the 4-year college / university at which you are
UGSP no later than 15-May-2019, no exceptions:
enrolled or will be enrolled in Fall 2019 for completion of Section B.
Fax To: 301-594-9606 – Attention: Mr. Adrian Warren
Undergraduate Institution’s Instructions – Complete Section B of
this form, which certifies whether the applicant for the UGSP award is
eligible for candidacy. Upon completion, return the form to the student
making this request. Certification is not complete without your
institution’s official seal or stamp.

Mail To:

NIH Undergraduate Scholarship Program
2 Center Drive / Room 2W11A
Bethesda, Maryland 20892-0230

Email To: [email protected] – Attention: Mr. Adrian Warren
Questions: Call Mr. Adrian Warren at 301-402-3831 or email [email protected].

SECTION A – The applicant completes this section. Items 1 through 3 may be completed before printing.
1. Applicant’s Name (last, first, middle)

1a. Other Names Used on Official Documents (last, first, middle)

2. University Student Identification Number
3. Email Address Used for Your UGSP Application
I authorize the institution indicated in Section B to release information about my academic, financial, service, and other pertinent information to me for the
completion of my application to the NIH Undergraduate Scholarship Program (UGSP).
Signature (Sign your full name in ink)______________________________________________________________ Date______________________
SECTION B – The Undergraduate Institution’s Financial Aid Office must complete parts 1 through 3 and return to the requesting student for
submission.
~ ATTENTION: The UGSP will not accept this form unless Question-2 is completed and the form contains the university’s official seal or stamp,
resulting in an automatic rejection letter to the student. ~
1. REQUIRED: Enrollment Status
- Is this student enrolled or accepted for enrollment as a full-time student for the 2019-2020 academic year? ¨ Yes ¨ No
- If currently enrolled, is this student in good standing? ¨ Yes ¨ No
- What is the anticipated graduation date for this student? ________________________________________________________________________
2. REQUIRED: Exceptional Financial Need Status – FAFSA information used to complete this form must be from 2017 or 2018 tax information.
- Does this student meet the threshold for EFN status for the 2019-2020 academic year, based on either 2017 or 2018 tax information?
See definition on page 3:

Select One:

¨ Yes

¨ No

AND

Select One:

¨ 2017

¨ 2018

3. REQUIRED: Certification of Academic Institution Financial Aid Office - The undersigned institutional representative certifies that, to the best of
his/her knowledge, the information reported above is accurate. This Certification should include the school’s seal or office stamp.
Name of School ________________________________________________________________________________________________________
University’s 9 Digit DUNS (Data Universal Numbering System) Number: ____________________________________________________________
Financial Aid Administrator’s Name (please print)_______________________________________Title____________________________________
Signature______________________________________________________________________________Date____________________________
Telephone____________________Fax Number____________________Email Address_______________________________________________
Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no
penalties for not participating or withdrawing from the study at any time. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of
the study. Information provided will be combined for all participants and reported as summaries.
Public reporting burden for this collection of information is estimated to average 18 minutes 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. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge
Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0299). Do not return the completed form to this address.

NIH 2762-3

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Last Updated – 31-August-2018

OMB Clearance Number: 0925-0299
Expiration Date: 30-June-2019

Instructions for Undergraduate Institution Certification Form NIH 2762-3
Exceptional Financial Need Status Identification of Individuals from Disadvantaged Backgrounds (Scholarship applicants must be from disadvantaged
backgrounds)
A student from a disadvantaged background is one who comes from a family with an annual adjusted gross income below a level based on low-income
thresholds according to family size, as published by the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and
adjusted by the Secretary, DHHS, for use in all health professions programs.
Qualification of EFN Status. Applicants who qualify as having EFN status must provide the Financial Aid Director of their undergraduate institution total
financial information, including: parent’s income and spouse’s income (if applicable), regardless of the student’s taxable status, and must be of EFN, as
defined by the Secretary, DHHS, (see above). The Financial Aid Director must certify this information and the institution’s certification of an applicant’s
EFN status must be included with the UGSP application package.
The Secretary, DHHS, will periodically publish these low-income levels in the Federal Register. (Please see the table below for the most recent
determination of low-income levels). If family income for the most recent calendar year is less than the income level indicated on the chart below for the
appropriate family size, students fulfill the definition of an individual having exceptional financial need (EFN). Students certified as being of EFN are
considered to be from disadvantaged backgrounds.
Low-Income Levels—Secretary DHHS

Persons in Family
(Includes Only Dependents Listed on
Federal Income Tax Forms)
1
2
3
4
5
6
7
8
More than 8 Persons

Admission Year Fall 2019 – Spring 2020
Family Income Level
Family Income Level
(Adjusted Gross Income for Tax Year 2017) (Adjusted Gross Income for Tax Year 2018)
Federal Register: Volume 82, Number 19,
Federal Register: Volume 83, Number 12,
31 January 2017, Page 8831.
18 January 2018, Page 2642.
$24,120.00
$24,280.00
$32,480.00
$32,920.00
$40,840.00
$41,560.00
$49,200.00
$50,200.00
$57,560.00
$58,840.00
$65,920.00
$67,480.00
$74,280.00
$76,120.00
$82,640.00
$84,760.00
$8,360.00 for Each Additional Person
$8,640.00 for Each Additional Person

Collection of this information is authorized by The Public Health Service Act, Section 410 (42 USC 285). Rights of participants are protected by The
Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. The information
collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information
provided will be combined for all participants and reported as summaries.
Public reporting burden for this collection of information is estimated to average 18 minutes 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. 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.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0299). Do not return the completed
form to this address.

NIH 2762-3

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