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Program - Dean'S Certification Of Reimbursable Items Form - Navy Armed Forces Health Professions Scholarship

Navy Armed Forces Health Professions Scholarship

Program – Dean’s Certification of Reimbursable Items

LAST 4 digits of your

Student Name

University

Social Security Number

Year Level

Graduation Date

Course of Study [ Medical - Dental - Optometry ]

I have reviewed the attached claim for reimbursement (SF-1164) in the amount

of $_____________, submitted by the above named student. I certify purchases

contained therein are consistent with those incurred by all students in this course

of study and year level, whether in the Navy’s Armed Forces Health Professions

Scholarship Program or not. I have lined through to DISALLOW any item not

REQUIRED by all students. I have made pen-and-ink adjustments to the item

quantity to show only quantity required, if necessary.

HEALTH INSURANCE (Fill in 1 if applicable, and initial 1, 2 or 3 below)

1) Is required and payable directly by the student, not billed on a separate tuition

invoice. The rate of coverage for a single (no spouse or dependants) school-

provided plan is $_______________ for the coverage period (enter dates)

_____/_____/_____ to _____/_____/_____ inclusive. Initial HERE _________

2) Is required but there is no school-provided plan. Initial HERE ________

3) Is NOT required or NOT claimed on attached SF-1164. Initial HERE ________

By my signature below I certify that, to the best of my knowledge and belief, the

items listed are required as outlined above, and no item claimed was or will be

billed on a separate tuition invoice.

Must be signed by the Dean, Residency Program Director or an authorized representative.

Signature of School Official reviewing claim ___

__________________________________________________________

Print or type name

Date

______________________________________________________

_________/________/_________

Title

Phone Number

_________________________________________________________

(_________) ________-____________

Revised 2/23/04 by Peggy Rice

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Program - Dean'S Certification Of Reimbursable Items Form - Navy Armed Forces Health Professions Scholarship