Form 3 NFLP Due Diligence Form

OMB Number: 0915-0314
Expiration Date: 08/31/2026

Exhibit F
Nurse Faculty Loan Program Forms
Capital Contribution Due Diligence Form

Federal

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 purpose of this information collection is to obtain performance data for the following: HRSA program
participants, program operations, and applications. In addition, these data will facilitate the ability to demonstrate alignment between
BHW Programs and the Nurse Faculty Loan Program. 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 08/31/2026. Public reporting burden for this collection of information is estimated to average 6.25 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 Modified2023-08-09File Created2022-11-21