2 Institution Loan Repayment Form

Faculty Loan Repayment Program
Fiscal Year 2015
Supplemental Form
Institution Employment/Loan Repayment Verification Form
To apply to the Faculty Loan Repayment Program, you must submit your online application, forms, and
supporting documents to http://www.hrsa.gov/loanscholarships/repayment/faculty/forms.pdf. Applications
that are mailed or faxed will not be accepted.

Please note that several supporting documents will need to be completed online as part of the FLRP online
application. Additional forms that must be uploaded (in a PDF format) and require an applicant’s signature,
are included in this Supplemental Forms package.
Questions? Call 1-800-221-9393 (TTY: 1-877-897-9910) Monday through Friday (except Federal
holidays) from 8:00 AM to 8:00 PM, ET.

OMB No. 0915-0150 Expiration: 10/31/2015
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 6 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 11A-33, Rockville, Maryland 20857.

Faculty Loan Repayment Program
U. S. Department of Health and Human Services
Health Resources and Services Administration
OMB No. 0915-0150, Expiration: 10/31/2015

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 July 31, 2015.
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.
This information is for statistical purposes only.
The institution is:
Located in a:

Historically Black

Hispanic Serving

Tribal

Medically Underserved Area (MUA)*
Health Professional Shortage Area (HPSA)*
*See http: //datawarehouse.hrsa.gov/GeoAdvisor/ShortageDestinationAdvisor.aspx

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 FLRP/HHS. 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 Application and Program Guidance, and submit this form, the letter and the supporting documentation to the
applicant for submission with his/her 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 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 Application and Program Guidance, and
submit this form, the letter and the supporting documentation to the applicant for submission with his/her application. The school must
also attach a copy of its loan repayment agreement to partially match the amount paid by FLRP/HHS.
*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