3 NFLP Due Diligence Form

OMB Number: 0915-0314
Expiration Date: XX/XX/20XX

Exhibit F
Nurse Faculty Loan Program
Federal Capital Contribution
Due Diligence Form
Institution Name: ____________________________________________________________________
Nursing Program: ___________________________________________________________________
(Example: DNP, PhD., MSN)
State: _____________________________________________________________________________
Institution Contact Person & Contact Information:
Name (first, last):_________________________________________________
Email: _________________________________________________________
Contact Number: ________________________________________________
Borrowers’ Personal Information:
Unique ID Number: ______________________________________________
Enrollment Start Date: ____________________________________________
Graduation Date: _________________________________________________
Grace Period End Date: ____________________________________________
First Payment Due Date: ____________________________________________
Date Defaulted on Loan: ____________________________________________
Date Institution Determined Loan Uncollectable: _________________________
Reason for Cancellation/ Write-off:_____________________________________
(a) Principal Amount Loaned $____________________

(b) Principal Amount Repaid $_____________________________

(c) Principal Amount Cancelled $__________________

(d) Principal Amount Outstanding (a-b-c=d) $_________________

(e) Penalty/Late Charges $________________________

(f) Interest $____________________________________________

(g) Interest Cancelled $ __________________________

(h) Interest Outstanding $ _________________________________

(i) Total Outstanding Balance $ ____________________
Public Burden Statement: The Nurse Faculty Loan Program — Program Specific Data Form, Annual Performance Report Financial Data
Form and Due Diligence Form will collect outcome and financial data to capture the NFLP loan fund account activity related to financial
receivables, disbursements, and borrower account data related to employment status, loan cancellation, loan repayment and collections.
Tracking of borrowers should cease when borrower accounts are closed due to full repayment/cancellation/collection. 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 0915-0314 and it is valid until xx/xx/xxxx. This information collection is
required to obtain or retain a benefit (42 U.S.C. 297n-1). 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.

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Below is a checklist of items to show due diligence for the NFLP loan determined uncollectible
(including for death & total/permanent disability).
1. Has the loan been reviewed and processed in accordance with the due diligence requirements for
loan debt collection and cancellation/write-off procedures at your institution?
File Typeapplication/pdfFile TitleNFLP Exhibit Forms_2022SubjectDetails forms available for granteesAuthorLWierzechowski@hrsa.govFile Modified2023-04-04File Created2022-11-21