Form OMB Form 1105-0086 OMB Form 1105-0086 Renewal of Incentive Payments

OMB Number 1105-0086. Expires xx/xx/xxxx

REQUEST FOR RENEWAL OF INCENTIVE PAYMENTS
ATTORNEY STUDENT LOAN REPAYMENT
FY 2010

(To Be Submitted Only by Attorneys Initially Selected in the FY 2008 or FY 2009 ASLRP)

Part 1:

ATTORNEY INFORMATION

1.

Name

3.

Mailing Addresses

2.

SSN

Work
Home

4.

Work Telephone

5.

Fax Number

6.

E-Mail Addresses

Work
Home

7.

Service Obligation

Did you incur any periods of leave without pay or time not in
a pay status in 2009?

(Select the appropriate
response and provide
any additional
information needed).
See Policy, Paragraph
D.4., for details.

YES

(enter dates:)

If absence was due to uniformed service, attach orders. If
absence due to compensable injury, attach appropriate
documentation.

NO

8.

Current Position (as
of May 1, 2010)

Include Component and Office of Assignment (AUSA's Include District)

9.

Is this the same
position you held
when originally
selected for

ASLRP?

YES I am in the same position and have not moved
within the Department
initials

***************************************
YES I am in the same position; however, I am moving to
a new position within the Department as of
(enter date: DD/MM/YY)
initials

(Select the appropriate
response).

NO I am not in the same position. I moved within the
Department.
initials
(This is the appropriate response if you moved from the position you originally held
at time of selection to a different position within the same component or U.S.
Attorney's Office or to a different component/office.)

If you moved to any position other than the one you held when
originally selected for ASLRP or when last renewed, or are moving
before July 1, 2010, you must complete Part I-A.

PART 1-A: LATERAL MOVES ( To be completed only by attorneys who have changed
positions since selection/renewal in 2009 or who are moving to a new position before July,

2010.)

Position Information: Place an "X" in the block that best describes your move
and enter the requested information:
1

I moved to another position within the same component or US Attorney's
Office.
My new position is:
My former position was:

2

I moved to another position in a different component or US Attorney's Office

(e.g., from Trial Attorney, Tax Division to Trial Attorney, Antitrust Division; or from Criminal
Division to a U.S. Attorney's Office; from the Eastern District of Virginia to the Western
District of Texas)
My new position and component are:

My former position and component were:

NAME:

SSN:

PART 2:LOAN AND SALARY INFORMATION: (Required for all renewals)
1. Enter the number of qualifying Federal student loans you hold

2. List your total qualifying Federal student loan indebtedness
(as of May 1, 2010): (Do not include debt associated with any private student

loans. Note that the $10,000 minimum debt does not apply to recertifications).

$

3. How much did you personally pay on your qualifying Federal
student loans from January 1, 2009, through December 31, 2009?
DO NOT INCLUDE FY 2009 ASLRP PAYMENTS ISSUED BY DOJ
ON YOUR BEHALF

$

4. What was your approved ASLRP payment (gross) in FY 2009?

$

5. Please check one of the blocks below and enter the appropriate information:
I hold an appointment under the excepted Federal service.
As of May 1, 2010, I hold the rank of
GS

Step

I am an Assistant U.S. Attorney paid under Title 28, USC.
$
6. What is your annual base salary as of December 31, 2009?
Attorneys holding GS status: Use the 2009 GS (base) pay table
www.opm.gov/oca/09tables/indexGS.asp. Do not include locality pay.
AUSAs: Use the AD pay scale in effect for December 2009 for your base salary.
Do not include locality pay.
7. If you graduated from law school in 2009, check here if your qualifying
Federal student loan repayments were tolled for part of the year.
8. Current loan information:
•

•
•
•

Complete the block below for each of your existing, qualifying federal loans.
o See the ASLRP Policy for information about qualifying loans
List them in the order you wish the incentive payments to be credited.
If you have more than one outstanding loan, use the loan information continuation page to
continue. Note that one block must be completed for each loan, even if all loans are with the
same lender.
Attach a letter/statement from each lender or loan servicing organization for each loan
indicating that the loan is current and in good standing and reflecting the 2009 payment history
and current balance. A monthly payment statement or cancelled check will not suffice. A
computer printout from a loan-holder's web site is acceptable provided it contains the required
information.

NAME:

Loan 1

SSN:
$

Amount of outstanding balance:
Date of above outstanding
balance:
Loan holder/servicing organization
(complete name, payment address,
telephone number)

Loan identification number
Type of Loan (e.g., Stafford, Direct)
Payment amount and frequency

(e.g., monthly/quarterly/annually)

Due date of the next payment
Amount you personally paid
between Jan 1 and Dec 31, 2009
Amount ASLRP paid on your

behalf in FY 2009
Amount due in the next 12 months

$

per

$
$
$

9. Please review your payment history for each loan to verify the distribution of
your 2009 ASLRP payment and to ensure that your loan holder applied it only to
qualifying Federal student loans, then check the appropriate block, below:
I have verified that distribution of FY 2009 ASLRP payments by my loan holder was
limited to qualifying Federal student loans
Yes
No
If you found erroneous distributions, check "No" and take corrective action immediately.
Attach a short statement addressed to OARM explaining what action you took. Future
ASLRP payments cannot be issued until proof of correction is provided to OARM.
OARM will continue to process your renewal request, but will not authorize further
payments until correction is confirmed in writing.
Please read the certification block carefully before signing and dating. Review the ASLRP policy
(http://www.usdoj.gov/oarm/aslrp/aslrp.htm ) for clarification if you do not understand the terms of
this certification. If you need further assistance, contact OARM.

Certification:
I certify that all the information I provided for ASLRP consideration is true and correct, including data
provided in the Justification. I further certify that I am not in default on any qualifying Federal student
loan, whether or not listed here. As part of this certification, I attest that:

•
•

I have read and understand the Attorney Student Loan Repayment Program Policy.
I understand that the ASLRP is an agency incentive program, not an entitlement, and is subject to
availability of funds as determined solely in the discretion of the Department of Justice.

•
•
•
•

•
•
•

I understand that ASLRP awards are subject to tax and withholdings, which are deducted before
payment is issued to the loan holder.
I am aware of the eligibility requirements, the "matching funds" provisions, and the requirement to
continue making personal loan repayments.
I understand that the Department does not guarantee future incentive payments beyond the initial
year of selection.
I understand that acceptance of ASLRP funding triggers a three-year service obligation and that
all payments issued on my behalf (pre-tax amounts) may be recouped if I fail to complete my
service agreement, and that my obligation is specifically to the Department of Justice and not to
federal service in general.
I acknowledge that periods of leave without pay or other periods in which I am not in a pay status
(except absence due to uniformed service or compensable injury) do not count toward completion
of my service obligation.
I certify that there are no misconduct, performance or discipline issues that render me ineligible
for this program.
I understand that I may be subject to administrative and/or disciplinary action, including but not
limited to termination of the loan repayment incentive, if I provide false information.

Signature
Date
Print, sign and date this document. Submit the original and one copy of your complete request
for renewal to your component / office ASLRP point of contact for further action. Retain a copy
for your records.

At this stage, a complete copy of your request must include the following:
Request for Renewal with:
• Part 1: Attorney Information
ψ Part 2: Loan and Salary Information
o Tab A : a current copy of each lender's statement of account status, 2009
payment history, and current balance on each loan
• if loans were consolidated since the award in FY 2009,
documentation from the lender showing that the original loan(s)
were qualifying loans
o Tab B : a copy of your resume
OARM WILL NOT PROCESS INCOMPLETE REQUESTS OR ATTACH MISSING
DOCUMENTS SUBMITTED SEPARATELY
Component/Office points of contact for submission of ASLRP requests are listed on the
OARM web page. If your component/office/bureau/board or equivalent is not listed,
request guidance through your supervisory channels on how to submit to the
component / office / bureau / department head.
Effect of Non-disclosure
Your submission of this Request for Consideration is voluntary; however, if the Request is
submitted, omission of significant information requested would preclude continued processing to
determine whether receive an incentive benefit.

General
This information is provided pursuant to the Privacy Act of 1974 (P.L. 93-597).
Authority for Collection of Information
5 U.S.C § 5379
Purpose and Uses
The main purpose for collecting the information requested on this form is to establish the terms
under which an individual receives a student loan repayment benefit under the Attorney Student
Loan Repayment Program. The information collected will be used as a basis for payroll actions
and to identify and validate qualifying Federal student loans. Accordingly, disclosure of
identifiable information, including your Social Security Number (SSN), may be made to the
Internal Revenue Service for tax withholding purposes, the Department of Agriculture for payroll
action, and to the Department of Labor for worker compensation claims, and to lending or
educational institutions to identify and validate qualifying Federal student loans. This
information may also be used by the Department of Justice for other lawful purposes including
law enforcement and in the event of litigation. In addition, these records, or information therein,
may also be used within the Department of Justice for study purposes, such as projection of
staffing needs, and/or creation of non-identifiable statistical data for reports to other Federal
agencies and Congress.
Information Regarding Disclosure of Your Social Security Account Number
Disclosure of the SSN is mandatory since it is the identifier used by the Internal Revenue
Service and for the withholding of taxes from your salary. The use of the SSN is necessary
because of the large number of present and former employees and applicants who have
identical names and birth dates, and whose identities can be distinguished only by the SSN. It
is used primarily to identify an employee's personnel, leave, and pay records and to relate one to
the other. In this regard, it is also used by the Department of Justice to locate records in order
to respond to lawful requests for information from former employers, educational institutions,
and financial or other organizations. It also may be used by the Department of Justice to
identify and validate qualifying Federal student loans. The information gathered through the use
of the number will be used only as necessary in personnel administration processes carried out
in accordance with established regulations and published notices of systems of records. The
SSN also will be used for the selection of persons to be included in statistical studies of
personnel management matters.