(please provide full name)
(DO NOT use Social Security Number; may be left blank for newly admitted students)
NEW Award Transmittal for FY'05 REVISION to a Previous Award Transmittal for FY'05
---Select Current Academic Program---Ph.D. Biochemistry & Molecular BiologyPh.D. Cell BiologyPh.D. Microbiology & ImmunologyPh.D. NeurosciencePh.D. PharmacologyPh.D. Physiology & BiophysicsPh.D. Tumor BiologyPh.D. Biomedical Sciences - UndifferentiatedPh.D. Biomedical Sciences - "Track" - Biochemistry & Molecular BiologyPh.D. Biomedical Sciences - "Track" - Cell BiologyPh.D. Biomedical Sciences - "Track" - Microbiology & ImmunologyPh.D. Biomedical Sciences - "Track" - PharmacologyPh.D. Biomedical Sciences - "Track" - Physiology & BiophysicsPh.D. Biomedical Sciences - GU/NIH - Biochemistry & Molecular BiologyPh.D. Biomedical Sciences - GU/NIH - Microbiology & ImmunologyPh.D. Biomedical Sciences - GU/NIH - PharmacologyPh.D. Biomedical Sciences - GU/NIH - Tumor BiologyM.D./Ph.D. - UndifferentiatedM.D./Ph.D. - Preclinical (M1)M.D./Ph.D. - Preclinical (M2)M.D./Ph.D. - Clinical (M3)M.D./Ph.D. - Clinical (M4)M.D./Ph.D. Biochemistry & Molecular BiologyM.D./Ph.D. Cell BiologyM.D./Ph.D. Microbiology & ImmunologyM.D./Ph.D. NeuroscienceM.D./Ph.D. PharmacologyM.D./Ph.D. Philosophy/BioethicsM.D./Ph.D. Physiology & BiophysicsM.D./Ph.D. Tumor BiologyM.D. Five-Year Research Track
NOTE: The figures provided for reference on this form are based on projected Academic Year 2004-2005 fees and expenses; should any applicable fees or expenses increase for Academic Year 2004-2005, it is understood that the award amount will be automatically adjusted accordingly.
FOR ALL STIPEND AWARDS (new awards, renewals, and revisions): Please complete the appropriate stipend paperwork, as outlined in the Biomedical Graduate (GDM) Financial Award Processing Guidelines. Completion of the section below alone will not initiate stipend payments.
Stipend amounts are subject to proration for new students based upon actual start date.
FY'05 Stipend Award NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account.
NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account.
Stipend Start Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Day01020304050607080910111213141516171819202122232425262728293031, Year20042005 Stipend End Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Day01020304050607080910111213141516171819202122232425262728293031, Year20042005 Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO STIPEND AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
Stipend Start Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Day01020304050607080910111213141516171819202122232425262728293031, Year20042005
Stipend Start Date
MonthJanFebMarAprMayJunJulAugSepOctNovDec Day01020304050607080910111213141516171819202122232425262728293031, Year20042005
Stipend End Date MonthJanFebMarAprMayJunJulAugSepOctNovDec Day01020304050607080910111213141516171819202122232425262728293031, Year20042005
Stipend End Date
Debit Amount #1
Debit GU Cost Center #1
Debit Amount #2
Debit GU Cost Center #2
Debit Amount #3
Debit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO STIPEND AWARD
Credit Amount #1
Credit GU Cost Center #1
Credit Amount #2
Credit GU Cost Center #2
Credit Amount #3
Credit GU Cost Center #3
Graduate Pre-Thesis $1,147.00 (per credit) $13,764.00 (per semester, 12+ credit full-time) $27,528.00 (per year, 12+ credit full-time) Graduate Thesis $2,500.00 (per semester) $5,000.00 (per year) Medical School $18,554.00 (1st Year, per semester) $37,108.00 (1st Year, per year) $18,429.00 (2nd Year, per semester) $36,858.00 (2nd Year, per year) $18,179.00 (3rd Year, per semester) $36,358.00 (3rd Year, per year) $18,034.00 (4th Year, per semester) $36.068.00 (4th Year, per year) Fall Semester 2004 (04C) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Graduate Pre-Thesis Graduate Thesis Medical School Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO FALL 2004 TUITION Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3 Spring Semester 2005 (05A) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Graduate Pre-Thesis Graduate Thesis Medical School Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO SPRING 2005 TUITION Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
Graduate Pre-Thesis
Graduate Thesis
Medical School
Fall Semester 2004 (04C) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Graduate Pre-Thesis Graduate Thesis Medical School
Graduate Pre-Thesis Graduate Thesis Medical School
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO FALL 2004 TUITION
Debit Amount #1 Debit GU Cost Center #1
Debit Amount #2 Debit GU Cost Center #2
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO FALL 2004 TUITION
Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3 Spring Semester 2005 (05A) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Graduate Pre-Thesis Graduate Thesis Medical School Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO SPRING 2005 TUITION Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
Credit Amount #1 Credit GU Cost Center #1
Credit Amount #2 Credit GU Cost Center #2
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO SPRING 2005 TUITION
Yearly Health Insurance $1,770.00 NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YEARLY HEALTH INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3 Summer Health Insurance $377.00 (charged to new students who will commence their studies with a summer laboratory research rotation) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO SUMMER HEALTH INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3 MD Disability Insurance (M.D./Ph.D. Students Only) $18.00 (1st & 2nd year) $23.40 (3rd year) $27.00 (4th year) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO MD DISABILITY INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3 MD Needle Stick Insurance (M.D./Ph.D. Students Only) $25.00 (1st year) $35.00 (2nd year) $60.00 (3rd & 4th year) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO MD NEEDLE STICK INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
Yearly Health Insurance
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YEARLY HEALTH INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YEARLY HEALTH INSURANCE
Summer Health Insurance
(charged to new students who will commence their studies with a summer laboratory research rotation)
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO SUMMER HEALTH INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO SUMMER HEALTH INSURANCE
MD Disability Insurance (M.D./Ph.D. Students Only)
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO MD DISABILITY INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO MD DISABILITY INSURANCE
MD Needle Stick Insurance (M.D./Ph.D. Students Only)
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO MD NEEDLE STICK INSURANCE Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO MD NEEDLE STICK INSURANCE
Fall Semester 2004 (04C) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YATES FIELD HOUSE FALL 2004 AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3 Spring Semester 2005 (05A) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YATES FIELD HOUSE SPRING 2005 AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
Fall Semester 2004 (04C) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account.
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YATES FIELD HOUSE FALL 2004 AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YATES FIELD HOUSE FALL 2004 AWARD
Spring Semester 2005 (05A) NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account.
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YATES FIELD HOUSE SPRING 2005 AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO YATES FIELD HOUSE SPRING 2005 AWARD
(one-time fee charged to all students)
NOTE: If the total amount is divided between more than one account number, please indicate the appropriate distribution for each account. Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO TRANSCRIPT FEE AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
Debit Amount #1 Debit GU Cost Center #1 Debit Amount #2 Debit GU Cost Center #2 Debit Amount #3 Debit GU Cost Center #3 COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO TRANSCRIPT FEE AWARD Credit Amount #1 Credit GU Cost Center #1 Credit Amount #2 Credit GU Cost Center #2 Credit Amount #3 Credit GU Cost Center #3
COMPLETE THE FOLLOWING SECTION FOR ADJUSTMENTS ONLYTO TRANSCRIPT FEE AWARD
By my electronic signature, as provided below in the "Prepared by" box, I confirm that I am authorized to approve disbursements from the above noted Georgetown University account(s), and hereby request payment of the above noted financial award(s) from the Georgetown University account(s) indicated to the biomedical graduate student named. I also accept responsibility for the monitoring of award postings as provided to me via Cost Center Status Reports (CSRs), and agree to process any needed adjustments in a timely fashion.
(type full name)
