GW M.D. Program

Office ofFinancial Aid

2016-2017 FINANCIAL AID REQUEST FORM

Name______GWStudentIdNumber ______

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DateofBirth Telephone E-mailAddress

During the 2016-2017 academic year, I will be a member of the class of (circle) 2020, 2019, 2018, 2017.

When did you, or will you, start medical school? ______(MMDDYY). I will graduate on______. (MMDDYY)

4th Year Students: willyou take anycoursesata medicalschool, outside the U.S., in spring 2017? Yes No

If yes please provide the name of the school, city and country:______

Note: credit hours taken at another university, outside the country, that will contribute to your degree may be eligible to be financed with federal student loans. You must submit written documentation from the Dean that the coursework being pursued at a foreign institution will contribute toward your degree.

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I wish to be considered for a need-based scholarship:

I am a new medical school candidate and wish to be consideredfor GW Medical School need-based scholarship.

I am a returning medical school studentand wish to be consideredfor GW Medical School need-based scholarship.

As a condition for receiving any need-based scholarship, IacknowledgethatIamrequiredtoaccept,borrow,andretain$20,500FederalDirectStaffordLoanofferedtome.OtherinstitutionalaidandGWMedical Schoolneed-basedscholarshipcombinedmaynotexceedthecostoftuitionandfees.Imustcompletethe2016–17FAFSAandNeedAccessformswith my information, my spouse’s information and my parent's information. I must also submit mine, my spouses and parents 2015 tax returns, W2s and all schedules.

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IwishtoborrowFederalDirectStudentLoans, only.IdonotwishtobeconsideredforaGWMedicalSchoolneed-basedscholarship.Imustcompletethe2016–2017FAFSAformwithmyinformationandthatofmyspouse(ifmarried).

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Iwishtoborrowaprivateeducationalloan.(please circle one) I will / willnotcompletetheFAFSAform to also obtain federal student loan(s).(Pleaseenterthefollowingprivateloaninformation):

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Private loanamount:$ LoanTypeLenderName

(PleaseattachyourprivateeducationalloanapplicationtoaprintedcopyofthisformandsubmitbothtotheGW M.D. Program Officeof FinancialAid.)

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I have other outside financial resources:

Listanyothersourcesandamountsofaidyouwillreceiveforthe2016–2017academicyear.(Includeanyscholarships,NHSC, Military HPSP, VAbenefits,stipends,employee tuitionbenefits, othertuition reimbursements, etc.)

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Source(s):If you have more than one resource please attach a list.Amount(s):$

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You must be registered at least half-time for any term for which you are applying for loans and/or institutional need-based aid.

You may only receive funding to cover the cost of attendance.The cost of attendance may be viewed on our website in the Application section.

IcertifythatIhavenotborrowedinexcessoftheloanlimitsunderTileIVprogramsatanyinstitution (if I have then I have also re-affirmed the debt with my servicer)andthattheinformationIhaveprovidedonthisformistrueandcomplete.IagreetonotifytheGW M.D. Program Office ofFinancialAidofanychangestomyinformation.Iunderstandthattheamountofneed-basedfinancialaid scholarship(FA),ifawardedtome,isforthe2016–2017academicyearonly,andisnotguaranteedtomeinfutureyears.IfurtherunderstandthatmyFAscholarshipissubjecttochangeandwillbeadjustedifI failtomaintainsatisfactoryacademicprogress,orifIreceivefundsfromanyoutside or institutional resources once I have been awarded. In addition, I have read this form inits entirety, and understand and agree to all rules, regulations, and requirements.

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StudentSignatureDate

Afteryousignthisform, pleasesaveandsubmit it,asanattachment,via emailtothe Office of Financial Aidat:, orviafaxat:202.994.9488.

You may also print and deliver this form to our office in Room 106 Ross Hall, 2300 I St. NW, Washington, DC 20037.

PLEASE NOTE: pre-printed information in this form is accurate at the time of publishing. Subsequent changes in federal regulations oruniversity policymayoccuratanytime,and maychangeapplicationrequirementsor programguidelines.

Thisformhelpsestablishyoureligibilityforstudentaidfunds.Intentionallyfalsestatementsormisrepresentation may subject youto a fine,imprisonment, or both, and mayeliminate youfromfutureconsiderationforassistancefromtheGeorgeWashingtonUniversity.Documentssubmittedinsupportofyourapplicationwillbeusedsolelytodetermineeligibility for financial assistance andcannot be returned.

TheGeorgeWashingtonUniversitydoesnotunlawfullydiscriminateagainstanypersononthebasisofrace,color,religion,sex,nationalorigin,age,disability,veteranstatus,orsexualorientation.Thispolicycoversallprograms,services,policies,andproceduresoftheuniversity,includingadmissiontoeducationalprogramsandemployment.Theuniversityissubjecttothe District ofColumbiahumanrightslaw.Inquiriesconcerningtheapplicationofthispolicyandfederallawsandregulations concerningdiscriminationineducation oremploymentprograms andactivitiesmay beaddressedtoDavid A. Greene, Associate VicePresidentforHumanResources,TheGeorgeWashingtonUniversity,RiceHall,Washington,DC20052,202.994.4433,ortotheAssistantSecretaryforCivilRightsoftheU.S.DepartmentofEducation.

Torequestdisabilityaccommodations,studentsshouldcontacttheOfficeofDisabilitySupportServices,202.994.8250(tdd/voice).

Security Information: GW is committedto assisting all members of the GW community in providing their ownsafety andsecurity.Informationregardingcampus securityand personalsafety includingsuch ascrime prevention, universitypoliceenforcementauthority, crime reporting policies, crime statisticsfor the most recentthree-yearperiod, and disciplinaryproceduresisavailableat TheGeorgeWashingtonUniversity;2033GStreet,NW;Washington,DC20052;202.994.6948.