**JACOB K. JAVITS FELLOWSHIP PROGRAM**

**ANNUAL PERFORMANCE, FINANCIAL NEED AND CERTIFICATION REPORT**

**(Authority: 34 CFR 650.20 and 650.44)**

**Important: The data requested is necessary to obtain a benefit.**

######## Section I: General Grantee Institution Information

**Instructions:** Please complete all information in this section. This
report must be completed for each cohort of Jacob K. Javits Fellows
attending your institution. The Department of Education tracks funds for
Jacob K. Javits Fellows according to the fiscal year in which they were
initially awarded a Jacob K. Javits Fellowship. All fellows initially
awarded a fellowship in a particular fiscal year constitute a cohort.
Thus, you must complete one report for each fiscal year listing all
fellows in that particular cohort.

Grant Number: P170B

Grantee Institution Name:

Grantee Institution Address:

Project Director:

Project Director Telephone Number:

Project Director Fax Number:

Project Director E-Mail Address:

Total Number of Javits Fellows in this cohort:

**JACOB K. JAVITS FELLOWSHIP PROGRAM**

**ANNUAL PERFORMANCE, FINANCIAL NEED AND CERTIFICATION REPORT**

**(Authority: 34 CFR 650.20 and 650.44)**

######### Section II: Individual Student Data

Instructions: For the electronic report, the system will prompt you for
the necessary information. Enter the requested data into the system for
each individual Javits fellow belonging to a cohort at your institution.

**1) Name of Fellow:** List the fellow to whom the grant number in
Section I applies. A list of each fellow belonging to this cohort at
your institution is provided.

> **Last Name First Name**

**Field of Study**

**Year and term student entered institution's graduate program:**

**Year Term**

**2) Current Educational Status of the Fellow:**

Currently Enrolled

Graduated

Transferred to (provide name of institution)

On Interruption of Study

Funding Discontinued Due to Failure to Make Substantial

Academic Progress

Funding Discontinued Due to Failure to Demonstrate

Financial Need

Withdrawn Due to Non-Academic Reasons

Completed Fellowship Tenure But Still Enrolled in

Graduate Degree Program

**Fellow Financial Need and Certification Information for the Budget
Period from**

**to**

**3) Months of Study:** If the fellow is currently enrolled, please
check the number of months of study projected for this fellow (maximum
12 months) during the budget period. The fellowship can be calculated on
a nine-month schedule if the student will not be enrolled during the
summer semester.

9 12

**4) Total Financial Need:** Enter this fellow\'s total financial need,
as determined under Part F of Title IV.

**Total Financial Need = Cost of Graduate Attendance - Student's
Estimated Family Contribution - Tuition & Fees.)**

Note: If the student\'s financial need is zero, he or she is not
eligible for any part of the Javits Fellowship.

**5) Stipend Request:** Enter the stipend request for this fellow for
the budget period. The stipend request should equal the fellow's
financial need and cannot exceed the maximum stipend amount for the
fiscal year.

**6) Institutional Allowance:** If this fellow will be enrolled for the
full academic year (12-month period including the fall, spring and
summer), enter the institutional payment amount for the budget period.
If this fellow will attend less than a full academic year, enter a pro
rata reduced amount.

**7) Prior-Year Stipend:** Enter the stipend for which this fellow was
determined to be eligible to receive in the [previous]{.underline} year
for this cohort.

**8) Unused Funds (if any):** Enter [any]{.underline} funds from the
stipend, institutional allowance, or both that your institution did not
use during the previous budget period due to one of the reasons listed.
For any "Other" reason not listed that applies, please provide a brief
explanation in the space provided.

-   If a student took a leave of absence after you submitted last
    year\'s report;

(Note: An Interruption of Study is not allowed in the first year of the
fellowship.)

-   If a student withdrew or graduated after you submitted last year\'s
    report; or

-   If a student transferred to another institution after you submitted
    last year\'s report.

-   Other

> **Stipend Unused Funds Institutional Payment Unused Funds**

**Required Certifications**

**9) Methodology Certification:** Certify that this fellow\'s financial
need was calculated using the same manner as that in which the
institution calculates all other graduate students\' financial need
under Part F of Title IV of the HEA by entering "Yes" in the space
provided.

**10) Academic Progress Certification:** Certify whether this fellow is
making substantial progress in his or her academic program by entering
"Yes" or "No." If "No," provide a brief explanation in the space
provided.

Yes

No

**11) "Full‑Time" Certification:** Certify that this fellow will be
devoting full time to his or her academic program, as required, by
entering "Yes" in the space provided.

**12) Part-Time Employment Certification:** Certify that this fellow
will not be engaged in gainful employment (other than on a part-time
basis as specified below) during the budget period by checking either
"Part-Time" or "Not Employed" below.

> Note: A fellow may work part time, but only for the institution he or
> she attends, and only in [teaching]{.underline},
> [research]{.underline}, or [similar activity approved by the
> Secretary]{.underline}.

Part-Time

Not Employed

**13) Leave Certification:** Certify whether a fellow will be on an
approved Interruption of Study for all or part of the award year by
indicating the number of months in the space provided. If the fellow
will not be on Interruption of Study, check "Not on Interruption of
Study."

Note: Section 701 of the HEA permits an institution to allow a
fellowship recipient an Interruption of Study for a period not to exceed
12 months for the purpose of work, travel, or independent study away
from the campus if the independent study is supportive of the fellowship
recipient\'s academic program. A fellow on an Interruption of Study does
not receive financial support during the period of his or her leave,
unless the leave is for the purpose of travel supportive of the
fellow\'s academic program or independent study supportive of the
fellow\'s academic program. Please provide a brief explanation in the
space provided if you believe the fellow is entitled to support under
these conditions.

Months

Not on Interruption of Study

Section III: AGREEMENT CERTIFICATION (REQUIRED BY 34 CFR 650.40) FOR THE
JACOB K. JAVITS FELLOWSHIP PROGRAM

This certifies that the applicant,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_(name
of institution), agrees that it will comply with the amended statute
(Title VII, Part A of the Higher Education Act of 1965) and regulations
(34 CFR Part 650) in implementing the Jacob K. Javits Fellowship
Program.

The authorized official identified below has reviewed all data entered
and certifies that the Annual Performance, Financial Need and
Certification Report is accurate and complete.

Name of Authorized Official

Title of Authorized Official Date

#### Paperwork Burden Statement

** **

**According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless such
collection displays a valid OMB control number.  The valid OMB control
number for this information collection is 1840-0630 and the expiration
date is 11/30/2010.  The time required to complete this information
collection is estimated to average 4 hours (or 160 minutes) per
response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the
information collection.  If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form,
please write to:  U.S. Department of Education, Washington, D.C.
20202-4651.  If you have comments or concerns regarding the status of
your individual submission of this form, write directly to:  The Jacob
K. Javits Fellowship Program, U.S. Department of Education, 1990 K
Street, N.W., Washington, DC 20006-8521. **

ED Form ED 40-1304