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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: 
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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 Withdrawn Due to Non-Academic Reasons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
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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 year for this cohort. 

$

$

$

$
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8) Unused Funds (if any): Enter any 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 

$ $
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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, research, or similar activity approved by the Secretary. 

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 702 of the HEOA 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; illness of the recipient or the recipient’s immediate family 

(spouse, parent or child); or active military service. The duration of the Interruption of 

Study must be not more than 12 months, or in the case of active military service, for the 

duration of the tour of duty. 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
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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

Disclosure of 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. Public reporting burden for this 

collection of information is estimated to average XX minutes/hours per response, including time for 

reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and 

completing and reviewing the collection of information. The obligation to respond to this collection is 

mandatory (citing authority)/required to obtain or retain benefit (citing authority) and voluntary. Send 

comments regarding the burden estimate or any other aspect of this collection of information, including 

suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, 

Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 

XXXX-XXXX. Note: Please do not return the completed XXXX (cite form or other applicable reporting 

mechanism) application to this address