**OMB No. 1840 -**  **0630 Expires xx/xx/xxxx** 

1 **JA COB K. JA** 

**VITS FELLOWSHIP PROGRA M**  **AN NUA**  **L PERFORMA NCE, FINA** **NCIA L NEED A** **ND CERTIFICA TION REPORT**  **(A uthority**  **: 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 accordi ng 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:**OMB No. 1840 -**  **0630 Expires xx/xx/xxxx** 

2 **JA COB K. JA** 

**VITS FELLOWSHIP PROGRA M**  **AN NUA**  **L PERFORMA NCE, FINA** **NCIA L NEED A** **ND CERTIFICA TION REPORT**  **(A uthority**  **: 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 Fello** **w:** List the fellow to whom the grant number in Section I applies. A l ist 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 pr ogram:** 

**Year Term**  **2) Current Educational Status of the Fello w:** 

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 Wi thdrawn Due to Non
-Academic Reasons Completed Fellowship Tenure But Still Enrolled in**OMB No. 1840 -**  **0630 Expires xx/xx/xxxx** 

3 Graduate Degree Program

**Fello w F**  **inancial 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 m onths of study projected fo r this fellow (maximum 12 months) during the budget period. T he fellowship can be calculated on a nine
- month schedule if the student will not be enrolled during th e 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 At** **tendance -**  **Student’s Estimated**  **Family Contribution**  **- Tuition & Fees.)**  Note: I f the student's fi nancial need is zero, he or she is not eligible fo r any part of t he Javits Fellowship.

**5) Stipend**  **Reque st:**  Enter the stipend request fo r this fellow for the budget period. T he stipend request should equal the fellow’s financial need and cannot exceed the maximum stipend amount for the fiscal year.

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

**7) Prior** **- Year**  **Stipend:** Enter the stipend fo r which this fellow was determined to be eligible to receive in the previous year for this cohort. $

$ $

$**OMB No. 1840 -**  **0630 Expires xx/xx/xxxx** 

4 **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 t he reasons listed. F or 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 Pay** **ment Unused Funds**

**Required Certifications**
**9) Methodology** 

**C ertification:**  Certify that this fellow's financial need wa s calculated using the same manner as that in which the institution calculates all other graduate students' financial need under Part F of Titl e IV of the HEA by entering “Yes” in the space provided.

**10) A cademic 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 explanatio n in the space provided.

Yes No $ $**OMB No. 1840 -**  **0630 Expires xx/xx/xxxx** 

5 **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 bu dget 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
-Ti me 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 70 2 of

t he HE OA permits an institution to allow a fellowship recipient an Interruption of Study for a period not to exceed 12 months fo r 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. T he duration of t he Interruption of Study must be not more than 12 months, or in the case of a ctive military service, for th e duration of

t he tour of

d uty. A fellow on an Interruption of S tud y does not receive financial support during the period of his or her leave, unless the leave is for the purpose of travel supportive of th e 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**OMB No. 1840 -**  **0630 Expires xx/xx/xxxx** 

6 **Section III:**  **A GREEMENT**  **CERTIFICA TION**  **(REQUIRED BY**  **34 CFR**  **650.40) FOR**  **THE JA** **COB K. JA**

**VITS FELLOWSHIP PROGRA M**  **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 Ac** **t of**  **1965) and**  **regulatio ns**  **(34 CFR**  **Part 650)**  **in implementing**  **the Jacob K. Javits Fello** **wship Program. The**  **authorized official**  **identified belo** **w has**  **review ed**  **all data**  **entered and**  **certifies that**  **the An**  **nual Performance,**  **Financial Need**  **and Certification**  **Report is**  **accurate and**  **comple te.** 
**Name of A uthorized Official** 

**Title of A uthorized 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