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.
Electronic Withholding Allowance Certificate
* required field
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Estimated Gross Award Amount
(60% of your Approved Educational Loan Amount): $51,000.00
Estimated Gross Award Amount is provided to assist in completion of your W4. The value provided is estimated and is subject to change. If you have questions on completing your W4, please refer to the IRS W4 Instructions or consult a tax expert. Nurse Corps does not provide tax guidance.
Filing status (Box 3 on Form W-4) *
If your last name differs from that shown on your social security card, check here (Box 4 on Form W-4)
Total number of Allowances (Box 5 on Form W-4) *
Additional withholding amount, if any (Box 6 on Form W-4)
Claim exemption (Box 7 on Form W-4) *
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mariah Fletcher |
| File Modified | 0000-00-00 |
| File Created | 2021-01-14 |