Form DD Form 2475 DD Form 2475 DOD Education Loan Repayment Program

LOAN PROGRAM (X one)

CONTROL NO.

DOD EDUCATIONAL
LOAN REPAYMENT PROGRAM (LRP)
ANNUAL APPLICATION

ACTIVE DUTY LRP
HEALTH PROFESSIONALS LRP

OMB No. 0704-0152
OMB approval expires

SELECTED RESERVE LRP

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, 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 the Department of Defense, Executive Services Directorate (0704-0152). Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION.
FORWARD YOUR FORM TO THE ADDRESS LISTED IN SECTION 1, BLOCK a.
PRIVACY ACT STATEMENT
AUTHORITY: 10 USC 2171, 2173, 16301, 16302, and EO 9397, November 1943 (SSN).
PRINCIPAL PURPOSE: To administer the DoD Loan Repayment Program.
ROUTINE USES: Release is restricted to the Department of Education, to the U.S. Public Health Service, to public and private higher educational
institutions, to financial institutions, to the Internal Revenue Service, to private bill collection agencies. The information provided may be used in
computer matching programs within the DoD or with any other affected Federal Agency for verification to determine your eligibility and/or compliance
with the benefit program requirements being applied for herein and to effect recovery of any improper payments made toward delinquent debts owed
by a beneficiary or former beneficiary.
DISCLOSURE: Voluntary; however, failure to provide your Social Security Number may delay processing of your LRP application.
1. PERSONNEL OFFICE VERIFICATION (To be completed by the designated personnel officer)
a. FORWARD COMPLETED FORM TO THIS ADDRESS (Include ZIP Code)

b. VERIFYING OFFICIAL.
I certify that this servicemember has performed satisfactorily.
(1) NAME (Last, First, Middle Initial)
(2) SIGNATURE

(3) DATE SIGNED
(YYYYMMDD)

2. SERVICEMEMBER DATA (To be completed by servicemember)
a. NAME (Last, First, Middle Initial)

c. SOCIAL SECURITY NO.

b. ADDRESS (Street, City, State, and ZIP Code)

d. TELEPHONE NO. (Incl. Area Code)

e. E-MAIL ADDRESS

f. TOTAL OF PRIOR
PAYMENTS

I authorize the release of my financial data by lender/holder to complete
entries in Section 4.
g. SIGNATURE

h. DATE SIGNED
(YYYYMMDD)

3. LOAN DATA (To be completed by servicemember)
a. NAME ON THE LOAN (Last, First, Middle initial)

d. LOAN

OF

b. ORIGINAL DATE OF PROMISSORY NOTE
(YYYYMMDD)

e. LOAN ACCOUNT NUMBER

LOANS

g. LOAN HOLDER ADDRESS (Include ZIP Code)

c. ORIGINAL LOAN AMOUNT

f. LOAN HOLDER NAME

D R A F T

h. TELEPHONE NUMBER
(Include Area Code)

4. LENDER VERIFICATION (To be completed by loan holder)
a. LOAN IN DEFAULT (X one)
YES

b. UNPAID PRINCIPAL BALANCE

c. OUTSTANDING BALANCE

d. ORIGINAL LOAN AMOUNT

NO

e. NAME AND ADDRESS OF INSTITUTION WHERE PAYMENT IS TO BE
SENT (Include ZIP Code)

f. FEDERAL TAX IDENTIFICATION NO. g. TYPE OF LOAN (See Instructions)

h. IS THIS A CONSOLIDATED LOAN?
YES

i. LOAN INTEREST

j. LOAN FEES

NO

k. CERTIFYING OFFICER.

As an official of the holding institution, I verify that this information is correct and current. Copy of the promissory note is enclosed.

(1) NAME (Last, First, Middle Initial)

(2) TITLE

(3) SIGNATURE

(4) DATE SIGNED
(YYYYMMDD)

FORWARD THIS FORM TO THE ADDRESS LISTED IN SECTION 1, BLOCK b.
5. REMARKS (Continue on back if necessary)

DD FORM 2475, 20101005 DRAFT

PREVIOUS EDITION IS OBSOLETE.

Adobe Designer 8.0

5. REMARKS (Continued)

D R A F T

DD FORM 2475,
"DOD EDUCATIONAL LOAN REPAYMENT PROGRAM (LRP) ANNUAL APPLICATION"
INSTRUCTIONS
SECTION 1. PERSONNEL OFFICE VERIFICATION
(To be completed by the designated personnel officer.)
1.a. - b. Self-explanatory.
SECTION 2. SERVICEMEMBER DATA
(To be completed by servicemember.)
2.a. - e. Self-explanatory.
2.f. Enter the total amount of money that has been paid by the
military under the Loan Repayment Program on your education
loans.
2.g. - h. Self-explanatory.
SECTION 3. LOAN DATA
(To be completed by servicemember.)
3.a. Name as it appears on the promissory note. 3.b. - c. Selfexplanatory.
3.d. Loan ___ of ___ Loans. A separate DD Form 2475 must
be completed for each loan if Servicemember has more than
one (1) loan. For example, loan 1 of 3 loans, loan 2 of 3 loans,
and loan 3 of 3 loans.
3.e. Loan Account Number of the current loan holder (usually
found on payment book or coupon or on promissory note).
3.f. - h. Identify the name, address, and telephone number of
the institution that currently holds your loan. Please list any
additional contact information in Section 5, Remarks.
SECTION 4. LENDER VERIFICATION
(To be completed by loan holder.)
4.a. Mark X in the appropriate box.
4.b. Self-explanatory.
4.c. Principal plus interest, plus any fees. Please specifically
list the fees in Section 5, Remarks.

DD FORM 2475 (BACK), 20101005 DRAFT

4.d. Self-explanatory.
4.e. Complete this block only if different than the one listed in
3.f. and 3.g.
4.f. Loan holder must provide their Federal tax identification
number for tax withholding.
4.g. Type of Loan. Select from list below: The loan must
qualify under the Higher Education Act of 1965, Title 4, Parts B
and E; the Health Education Assistance Loan under Part C, Title
VII, Public Health Service Act; under Part B, Title VIII;
Health Professional Loans that the SECDEF determines to be
critical to meet wartime medical skill shortages; William D. Ford
Federal Direct Loan; or any loan incurred for educational
purposes made by a lender that is: (1) an agency or
instrumentality of a State; (2) a financial or credit institution
(including an insurance company) that is subject to examination
and supervision by an agency or the United
States or any State; or (3) from a pension fund or a non-profit
private entity (subject to case-by-case review/approval by the
Office of the Undersecretary of Defense for Personnel and
Readiness (Military Personnel Policy) (Accession Policy)
through each Service's Education Representatives).
4.h. If multiple loans have been consolidated, mark (X) "Yes"
or "No" indicating consolidating action.
4.i. - k. Self-explanatory.
After completion and signature, the personnel records
custodian will forward this form to the address listed in Section
1, block b.
SECTION 5. REMARKS.
Use this section to enter additional information that will assist
in processing this application.

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