Form 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 $

7. Interest Cancelled $ (h) Interest Outstanding $

1. Total Outstanding Balance $

Public Burden Statement: The Nurse Faculty Loan Program Forms 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 13N82, Rockville, Maryland, 20857.

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?

Yes □ No □

2. Is a promissory note(s) completed?

Yes □ No □

3. Was a repayment schedule completed?

Yes □ No □ NIA □

4. Was an entrance (loan disbursement) process completed?

Yes □ No □

5. Was an exit process completed?

Yes □ No □ NIA □

6. Were deferments, forbearance or employment-based cancellations granted on this loan?

Yes □ No □ NIA □

7. Was the loan referred to a commercial or in-house collection agency?

Yes □ No □ NIA □

8. Was this loan litigated or reported to a credit bureau?

Yes □ No □ NIA □

9. What was the reason for Write-off determination (e.g. Discharged through bankruptcy, unable to locate, etc.)?

10. Has the write-off/cancellation been reported in the APR (include report year)?

Yes □ No □

Other Comments:

Project Director/Authorized Official’s Signature Date

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