Form 1 UGSP

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

U.S. Department of Health and Human Services
National Institutes of Health

NIH Undergraduate Scholarship Program

Undergraduate Institution
Certification

Applicant’s Instructions:
Please complete Section A. Give this form and one of the return envelopes
to the financial aid office at the school at which you are enrolled or will be
enrolled starting September 2007.
Undergraduate Institution’s Instructions:
Please complete Section B and return the form in the envelope provided,
or mail to National Institutes of Health Undergraduate Scholarship
Program, 2 Center Drive, Room 2E20 (MSC 0230), Bethesda, Maryland
20892-0230. If you have any questions, please call 888-352-3001 or
e-mail .

Section A — The applicant completes this section.
1. Applicant’s Name (last, first, middle) Please print.

1a. Other Names Used (last, first, middle) (if any school records are
maintained under that name)

2. Social Security Number (We collect your Social Security Number (SSN)
to verify your identity, to determine your eligibility for the Undergraduate
Scholarship Program, and to keep track of the federal funds you receive. We
also use your SSN for servicing purposes under the Undergraduate
Scholarship Program. We also use this information to determine the amount
of that assistance. See Privacy Act Information in this package.)
____________ - ________ - ____________

I authorize the institution indicated in Section B to release information about my academic, financial, service, and other pertinent information to
administrators of the NIH Undergraduate Scholarship Program (UGSP) and to other authorized Government officials. This release is valid for six months
after completion of UGSP requirements.
Signature (Sign your full name in ink.)
Date
 __________________________________________________________________________________________________________________________
Section B — To be completed by Academic Institution Financial Aid Office
1. Enrollment Status
Do you expect that this student will be enrolled full-time for the 2008–2009 academic year?

 Yes  No

If currently enrolled, is this student currently in good standing?

 Yes  No

 Not Applicable

Has this student been accepted for enrollment as a full-time student for the 2008–2009 academic year? (For new students.)  Yes  No
What is the anticipated graduation date for this student?

Month_______ Year_______

2. Exceptional Financial Need Status Does this student qualify for “exceptional financial need” (EFN) status as defined by the Secretary, Department
of Health and Human Services? (See back for definition of EFN.)
 Yes
 No
3. Additional Sources of Financial Support
____________________________________________ (name of student) has been awarded the following financial aid for the 2007–2008 academic year:
$__________________ student loans
$___________________ institutional scholarships
$__________________ non-institutional scholarships/grants
Continuation of this financial aid support ( will,  will not) be reduced by receipt of NIH UGSP funding.
4. Calculation of Eligible Tuition, Education, and Living Expenses The UGSP scholarship covers up to $20,000 per academic year toward (1) tuition,
(2) reasonable education expenses, and (3) reasonable living expenses.
Tuition: What is the tuition amount for this student in the 2008–2009 academic year? $_________________________________________
Educational Expenses: What are the average educational expenses for the categories listed below during the 2008–2009 academic year?
Books $ ___________________________________________

Other (specify)

$ _________________________________________

Laboratory fees $ ___________________________________

Other (specify)

$ _________________________________________

Living Expenses: W hat are the average room, board, and transportation expenses for the 2008–2009 academic year for this student?
Room $ ______________________

Board $ _______________________

Transportation $ ___________________________

5. Certification by 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 ________________________________________________________________________________________________________________
Financial Aid Administrator’s Name (please print) ______________________________________ Title _________________________________________
Signature ______________________________________________________________________ Date _________________________________________
Telephone _____________________________
NIH 2762-3
PAGE 1 (FRONT)
Revised 08/07

Fax Number ____________________________ E-mail Address ________________________________

Public reporting for this collection of information is estimated to average 30 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 (0925-0438). Do not return the completed form to this address.

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

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 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). This information must be certified by the Financial Aid
Director 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

Family Income Level

(Includes only dependents listed
on Federal income tax forms)

(Adjusted gross income,
rounded to the nearest $100)

1
2
3
4
5
6
7
8

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $20,420
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27,380
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34,340
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41,300
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48,260
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55,220
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62,180
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69,140

Federal Register, Volume 72, Number 96, May 18, 2007, p. 28062.

NIH 2762-3
PAGE 1 (BACK)
Revised 08/07