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**INSTRUCTIONS FOR COMPLETING THE ANNUAL PERFORMANCE, FINANCIAL NEED AND CERTIFICATION REPORT FOR THE JACOB**  **K. JAVITS FELLOWSHIP**  **PROGRAM Section I: General Grantee Institution Information**  **Please be sure to complete one form for each**  **cohort of Jacob K.**  **Javits Fellows attending your institution.**  The Department of Education tracks funds for Jacob K. Javits Fel lows according t o the fiscal year in which they were initial ly awarded a Jacob K. Javits Fel lowship. All fellows init ial lyawarded a fellowship in a particul ar fiscal year constitute a cohort. Thus, you must compl ete one form for each fiscal year l isting al l fellows in t hat particul ar cohort. **Determine the level of financial need of each Jacob K.**  **Javits Fellow on the enclosed l**  **ist before completing these forms.** Each Jacob K. Javits Fel low's demonst rated l evel of financial need mustbe reflect ed on these forms. Financial need is det ermined each year on the basis of the requirements for need analysis prescribed by Part F of Titl e IVof the Higher Education Act of 1965, as amended ( HEA), except that **tuition and fees are excluded from the student's cost of attendance**  . Tuition and fees are excl uded because t he fellowship includes an inst itutional payment that is provided in l ieu of tu ition and fees normally charged t o the student. Your institution's financial aid office may be abl e t o provide you with this information or assistance in cal culat ing financial need. Continuing fel lo ws **must** complet e a Free Appl ication for Federal St ude nt Aid (FAFSA) immediatel y and submitt he results t o your institution for financial need det erminat ion. The FAFSA is avail abl e on the I nternet at www.fafsa.ed.gov

. St udents may also obt ain a hardcopy format in the f inancial aid office at your institution.
**Grant Number:** Ent er the ten

- digit grant number that al ways begins with “ **P170B.”** There is a separate grant number for each cohort (group) of Jacob K. Javits fel lows. Remember t hat a cohort incl udes all fellows init ial lyawarded a fel lowship in a particul ar fiscal year. I nsert the number from the col umn ent itl ed "PR#" on your grant aw ard notification document or on the encl osed listof continuing fel lo ws ( if any). The first two digits after the B indicate the fiscal year of the initial award. For example, P170B010001 is the number for a fel low init ial ly awarded in fiscal year 2001. This number remains t he same t hroughout the2

period of a student's fel lo wship. I n some documents, you may see a 2

- digit suffix, for exampl e, - 99. I gnore the suffix for purposes of compl eting this form. The suffix indicates the current fiscal year. **Grante e Institution Name:**  Self

- expl anatory. **Grantee Institution Address:** Self

- expl anatory. **Project Director:** Pl ease indicate the name of the person at the institution whom the Department of Education shoul d cont act regarding the administration of Javits Fel lowships. The Javits Program Office al so frequentl y refers to this individual as t he “Javits Coordinator.” **Project Director Telephone Number:** Self

- expl anatory. **Project Director Fax Number:** Self

- expl anatory. **Project Director E -**  **Mail Address:** Self

- expl anatory. **Total Number of Javits Fellows in this cohort:** List the total number of al l fellows initial lyawarded a fellowship in t he fiscal year referenced in this report.
**Section II: Individual Student Data Name of Fellow:**  List the fel lo w t o whom t he grant number in Section I appl ies for this report. A l ist of fel lo ws atyour institution is provided. Enter the l ast name first, fol lowed by t he first name. NOTE: Never change a fellow from one cohort year ( and the accompan ying ten

- digit grant number) to another. Please enter “0” for any fellow who failed to submit his or her financial aid forms in time for you to calculate his or her financial need. **Field of Study:** List the fiel d of study under which the fellow was awarded a Javits fel lowship. **Year and Term student entered institution’s graduate program:** Self

- expl anatory. **Current Educational Status of the Fellow:** Pl ease indicate the status of the fel low3

on the report form for the current budget period as fol lows: "Currentl y Enrol led Fel low,” "Graduated,” “Transferred to Name of I nstitution ,” “On I nterruption of St udy,” “Funding Discontinued Due to Fail ure to Make Substantial Academic Progress,” “Withdraw n Due to Non

- Academic Reasons," or "Complet ed Tenure But Stil l Enrolled.” **Fellow Financial Need and Certification Information for the Budget Period from**

**to :** This is the next scheduled budget period for which you must report financial need and cert ification information in order to request continuation funding for each fel low. Specifically, t he dates for the next schedul ed budgetperiod are September 1, through August 31, . **Months of Study:** Ent er the number of months of study projected for the fel low (m aximum 12 mont hs) during the budget period covered by this report. The fel lowship can be calculat ed on a nine

- mont h schedule if t he st u dentwill not be enrol led during t he summer semest er. **Total Financial Need:** Ent er the fel low's t otal financial need, as determined under Part F of Titl e IV

. Total Financial Need = Cost of Graduate Attendance

- St udent ’s Est imat ed Family Cont ribution

- Tuition & Fees. Note: I f the student's financial need is zero, he or she is not eligible for any part of the Javits Fel lo wship. **Stipend Request:** Ent er the stipend request for each fel low. The stipend request should equal t he fellow's financial need and /or the maximum st ipend amount for the fiscal year, whichever is less

. **Institutional Allowance:** Ift he fellow will be enrolled for t he full acade mic year (12

- mont h period including t he fal l, spring and summer), enter the institutional payment amount. I f the fel lo w will attend l ess t han a full academic year, ent er a pro rata reduced amount. Note: The fellowship provides an institutional allowance that is in lieu of all tuition and fees normally charged to the student for the period of enrollment. The allowance must be reduced by any amount collected by the institution from a fellow for tuition and other expenses related to the fellow's educationa l program (3 4 CFR 650.41).4

**Prior -**  **Year Stipend:** Ent er the stipend for which this fel low was det ermined t o be eligible t o receive in the previous year for this cohort. **Unused Funds (if any):** Ent er any funding provided for the fel low t hat your institution did not use from the stipend, institutional allowance, or bot h for one of the reasons l isted bel ow. For any “Other” reason that appl ies, pl ease provide a brief expl anation in the space provided.

 If a student took a leave of absence after you submitted last year's report; (N ot e: 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 **Required Certifications:** These constitute al l of t he certifications which are required to establ ish t he eligibility of each Javits fel low t o receive continuation funding for the next schedul ed budgetperiod. These certifications al so ensure the compl iance of the grantee institution requesting continuation funding on behal f of the fel lo w for the budget period. **Methodology Certification:** Certify that the fel low's financial need was calculat ed using t he same manner as t hat in which the institution cal culat es all other graduate students' financial need under Part F of Titl e IVof the HEA by entering “Yes.” **Academic Progress Certification** : Certify whether the fel low is making substantial progress in his or her academic program by entering “Yes” or “No.” I f “No,” provide a brief expl anation in the space provided. **“Full -**  **Time” Certification:** Certify that the fel low will be devot ing their ful l t ime t o his or her acade mic program, as required, by entering “Yes.” **Part -**  **Time Employment Certification:** Certify that each fel low will notbe engaged in gainful employment( other than on a part

- tim e basis as specified bel ow) during the budget period by entering “Yes.” 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

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**Leave Certification:** Certify whether a fel low will be on an approved In terruption of Study for al l or partof the award year by indicating the number of months in the space provided. I f the fel lo w will notbe on I nterruption of Study, check “Not on I nterruption of Study.” Note: The legislation for the Javits program 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 t he fellowship recipi ent's academic program. In t he case of other exceptional circumstances, such as active duty military service or personal or family member illness, the institution of higher education may also permit the fellowship recipient to interrupt periods of study f or the duration of the tour of duty ( in the case of military service) or for not more than 12 months ( in any other case), but without payment of the stipend. 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. In the space provided, please provide a brief explanation if you believe the fellow i s entitled to support under these conditions.6

**Section III: Agreement Certification (required by 34 CFR 650.40) for the Jacob**  **K. Javits**  **Fellowship Program:**  **U pon**  **completion of**  **electronic report,**  **the applicant,**  **who is**  **the grantee**  **institution, must**  **agree that**  **it will**  **comply with**  **the amended**  **statute (Title**  **VII, Part**  **A of**  **the Higher**  **Education Act**  **of 1965)**  **and regulations**  **(34 CF**  **R Part**  **650) in**  **implementing the**  **Jacob K.**  **Javits Fellowship**  **Program. Also, an authorized official must review all data entered and provide a signature**  **certification that**  **the Annual**  **Performance, Financial**  **Need and**  **Certification Report is accurate and comple te.** 

**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 aver age 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 collect** **ion 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 fo rm or other applicable reporting mechanism)**  **application to this address**
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