Form Approved

OMB No. 1840-0630

Expiration Date: 11/30/2007

U.S. Department of Education

Washington, DC 20202-5247
REPORT OF FINANCIAL NEED AND CERTIFICATION FOR THE JACOB K. JAVITS FELLOWSHIP PROGRAM
(Authority: 34 CFR 650.20 and 650.44)

Part I: FY xxxx Jacob K. Javits Fellowships

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

1. Name and Address of Grantee (Institution) 4a. Contact Person
2. Grant Number: P170B __ __ __ __ __ __

3. Budget Period Covered by Report (Dates): b. Phone Number

( )
a. From ______________ b. To ______________

5. Name of Fellow (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K)
(Last, First, & Middle
Initial) Total Stipend Months Institutional Unused Full- Leave Academic Employment Methodology
Status Progress Certification
Financial Request of Allowance Funds Time Status Certification
Need Study Status

6. Totals:

ED Form ED 40-1304