Form 5-1 NC LRP COI 1-Accept or Decline Award Page - Revised

OMB Number: 0915-0140

Expiration Date: 5/31/2020

Public Burden Statement:

The purpose of the Nurse Corps Loan Repayment Program (NURSE CORPS LRP) is to assist in the recruitment and retention of professional Registered Nurses (RNs) dedicated to working in health care facilities with a critical shortage of nurses or working as nurse faculty in eligible schools of nursing, by decreasing the economic barriers associated with pursuing careers at such critical shortage facilities or in academic nursing. 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. The OMB control number for this information collection is 0915-0140 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (Section 846 of the Public Health Service Act, as amended (42 U.S.C. 297n). Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. 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 Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.

Note: Anywhere the year 2019 is displayed will automatically update to year 2020 in the system. Please make updates to months and days as needed.

NURSE Corps Loan Repayment Program Application

Your application has been identified as "finalist" for a 2019 Nurse Corps Loan Repayment Program award. Below is your Approved Educational Loan Amount and the current Site where you are employed. By accepting these terms and clicking the Sign and Submit button, you will be electronically signing your contract. This is not a guarantee of an award; however, if funding is available and your contract is countersigned by the Secretary of the U.S. Department of Health and Human Services designee, you will receive a 2019 Nurse Corps Loan Repayment Program award. If you are selected for an award; you will not be allowed to terminate your contract prior to the service deadline. All matters of non-compliance will be subject to default of the Nurse Corps Loan Repayment Program agreement.

You are required to complete the following steps by the deadline date provided in the Confirmation of Interest email.

Please also make sure that your contact information is up to date on the account settings page.

Your overall Application Status is: Finalist For Award

View your submitted application

Approved Educational Loan Amount: $85,000.00

Estimated Gross Award Amount (60% of your Approved Educational Loan Amount): $51,000.00

Please Note: The above Estimated Gross Award Amount is a pre-tax value. Taxes will be withheld during disbursement.

Step 1

Below is the Site information that you submitted with your application:

Site Information

Site Name Site Address

L.A. County Health Services--Hubert H. Humphrey 5850 S Main St Los Angeles, California 90003 1215

Are you currently working full-time (as defined for Nurse Faculty) or at least 32 hours (for RNs) at the site above? (If the site information is not correct, please contact the Customer Care Center at 1-800-221-9393 prior to completing this request.) *

Yes

No, and I understand this makes me ineligible to accept this award.

Step 2

Please confirm or decline your intent to accept the Nurse Corps LRP award below. *

I wish to accept the 2019 Nurse Corps LRP Award, contingent on availability of funding.

I wish to decline the 2019 Nurse Corps LRP Award.

Step 3

Please enter your banking information. This account will be used to deposit your Nurse Corps Loan Repayment award.

Bank Name *

Account Type *

Routing Number * Tooltip

Re-enter Routing Number *

Account Number * Tooltip

Re-enter Account Number *

Step 4

State whether you would like to receive your tax documents electronically and be available from the Portal or if you would like to receive them by mail.

AGREEMENT

All tax document communications (e.g., notice of availability of tax forms or of a change in hardware or software required to access the forms) will be sent to the email address linked to your BHW Program Portal account. If you wish to receive your tax documents electronically, you will need to ensure your portal contact information is up to date and you have access to the email address you provided. Your email address can be updated from the "My Contact Information" section on the BHW Program Portal landing page. If BHW sends an email notice that your tax documents are available and it is returned as undeliverable, and BHW is unable to obtain another valid email address for you, the notice will be sent by mail within 30 days after the email notice is returned.

If you consent to receive your tax documents electronically by checking the "Yes" delivery preference option below, you will be able to access them using "View Tax Documents" link from the "My Tax Information" section on the BHW Program Portal landing page. Documents will be in PDF format. Please note you may be required to print your tax documents to include with your Federal, State, or local income tax return.

Documents will be retained in accordance with the agency's records management policy. While you are a program participant, you will have access to all tax documents that you consented to receive electronically through the BHW Program Portal.

As a scholarship or loan repayment program participant, you have the option to receive your tax documents (Form W-2, and if applicable, Form 1099-Misc.) in an electronic format. If you do not consent to receive your tax documents electronically, you will continue to receive paper copies via mail. If you consent to receive your tax documents electronically, you will receive your electronic documents for the applicable tax year immediately following the date of your consent and all future years, unless you withdraw your consent.

You may receive paper tax documents or electronic tax documents but not both. Tax documents will be furnished based on your delivery preference in effect as of January 16th each year. You are not required to update your preference yearly. However, you will be able to change your preference using the "Set My Tax Document Delivery Preference” link in the "I Need to" section of the BHW Program Portal until 11:59 PM ET January 15th of each year.

If you previously set your preference to receive electronic tax documents but subsequently change your preference to receive paper copies, your withdrawal of consent will apply only to future tax documents that have not already been provided, electronically.

Tax documents will be made available through the BHW Program Portal, but the HHS Program Support Center (PSC) is responsible for preparing these documents. If there is an error in your tax documentation, you will need to contact PSC at 301-443-3020. If PSC corrects a tax form that was previously furnished electronically, the corrected form will be made available through the BHW Program Portal.

If you previously set your preference to receive electronic tax documents but subsequently change your preference to receive paper copies, your withdrawal of consent will apply only to future tax documents that have not already been provided, electronically.

All tax document communications (e.g., notice of availability of tax forms or of a change in hardware or software required to access the forms) will be sent to the email address linked to your BHW Program Portal account. If you wish to receive your tax documents electronically, you will need to ensure your portal contact information is up to date and you have access to the email address you provided. Your email address can be updated from the "My Contact Information" section on the BHW Program Portal landing page. If BHW sends an email notice that your tax documents are available and it is returned as undeliverable, and BHW is unable to obtain another valid email address for you, the notice will be sent by mail within 30 days after the email notice is returned.

If you consent to receive your tax documents electronically by checking the "Yes" delivery preference option below, you will be able to access them using "View Tax Documents" link from the "My Tax Information" section on the BHW Program Portal landing page. Documents will be in PDF format. Please note you may be required to print your tax documents to include with your Federal, State, or local income tax return.

Documents will be retained in accordance with the agency's records management policy. While you are a program participant, you will have access to all tax documents that you consented to receive electronically through the BHW Program Portal.

Tax documents will be made available through the BHW Program Portal, but the HHS Program Support Center (PSC) is responsible for preparing these documents. If there is an error in your tax documentation, you will need to contact PSC at 301-443-3020. If PSC corrects a tax form that was previously furnished electronically, the corrected form will be made available through the BHW Program Portal.

Please select your tax document delivery preference *

Yes, I have read the above Disclosure Statement and consent to receive my tax documentation electronically via my BHW portal account.

No, I do not wish to receive tax documents electronically. I wish to receive documents via mail.

Decline Offer of the Nurse Corps LRP Award

* required field

Back

You have indicated that you are not interested in receiving the Nurse Corps LRP award. If this is not correct you may go back and change your answer on the previous page.

Please indicate your reason for declining the Nurse Corps LRP award. *