Form lrp loan form lrp loan form lrp loan form

OMB No. 0915-0127

Expiration Date:

LOAN INFORMATION AND VERIFICATION FORM

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH RESOURCES AND SERVICES ADMINISTRATION

BUREAU OF HEALTH PROFESSIONS

DIVISION OF NATIONAL HEALTH SERVICE CORPS

NATIONAL HEALTH SERVICE CORPS LOAN REPAYMENT PROGRAM

INSTRUCTIONS:

APPLICANT: Complete one copy of this form for each loan you are applying to have considered for repayment under the NHSC Loan Repayment Program. To each form, attach a copy of the loan agreement; also attach a copy of your loan application, if possible. Please print clearly and complete all this form to expedite verification. Please note that incomplete information may delay verification of your loan.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0127. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33 Rockville, Maryland, 20857.

1. Applicant's Name (Last, First, Middle) 2. Applicant's Social Security No.

______________________________________________________________________________________________

3. Applicant's Complete Address 4. Applicant's Telephone No.

_______________________________________________________________________________________________

5. Name of Lending Institution 5.a. Lender’s Telephone No. 6. Loan Account No.

________________________________________________________________________________________________

7. Full Address of Lending Institution

________________________________________________________________________________________________

8. Was the loan sold? (If you are not sure, check with your lender) If "yes," give the secondary loan holder's name and full address.

Yes  No 

9. Original Date of the Loan ____________________ 10. Original Amount of the Loan ________________

11a. Current Balance (Principal & Interest) $ as of (date)

11b. Interest Rate ________

12. Purpose of the Loan as Indicated on the Loan Application: ___________________________________________________

13. Type of Loan (e.g., GSL, NDSL, HEAL) Please spell out the type. ________________________________________________

14. Loan in Default? Yes  No  Date of Default: _______________

15. Loan Under a Federal Court Judgment? Yes  No  Date of the Judgment: ____________

FOR CONSOLIDATED UNDERGRADUATE AND GRADUATE EDUCATION LOANS - If you have consolidated your loans for undergraduate and graduate education costs, you must attach a copy of the loan documents for health professions education costs that were consolidated into a new loan.

WARNING - Any person who knowingly makes a false statement or misrepresentation in this loan repayment transaction, bribes or attempts to bribe a Federal official, fraudulently obtains repayment for a loan under this statute, or commits any other illegal action in connection with this transaction is subject to a fine or imprisonment under Federal statute. I have read this statement and understand its contents.

CERTIFICATION BY APPLICANT - I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Secretary of HHS for repayment of the educational loans I have submitted with my application hereof, incurred solely for the costs of undergraduate or graduate education, including reasonable living expenses, leading to a degree in the health profession in which I would satisfy my NHSC LRP service commitment. I hereby authorize the Government or financial institution named in item 5 or 8 above to release this information about the loan to the administrators of the NHSC Loan Repayment Program.

__________________________________________________ ____________________

SIGNATURE OF APPLICANT DATE