Form 0127-3 Loan Information and Verification Form

National Health Service Corps
Loan Repayment Program
U.S. Department of Health and Human Services
Health Resources and Services Administration

LOAN INFORMATION AND VERIFICATION FORM
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 National Health
Service Corps (NHSC) Loan Repayment Program (LRP). To each form, attach a current account statement showing your loan balance and
interest rate. Please print clearly and complete the entire form to expedite verification. Please note that incomplete information will render
your loan ineligible.
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/current 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 applicable loan documents for the education costs that were consolidated into a new
loan. See Program Overview – Consolidated/Refinanced Loans for more detail.
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 further certify that the above-identified loan
was incurred solely for the costs of undergraduate or graduate education pursued prior to my receipt of the degree in the health profession in
which I would satisfy my NHSC LRP service commitment.
AUTHORIZATION FOR DISCLOSURE: Pursuant to the Right to Financial Privacy Act of 1978 (RFPA) (12 USC 3404), having read the attached
statement of my RFPA rights, I hereby authorize the government or financial institution named in item 5 or 8 above to release financial
records relating to the educational loan(s) identified above to the HHS and/or its contractors for the purpose of assessing and verifying the
amount and eligibility of the educational loan for payment under the NHSC LRP. This authorization is valid for 3 months from the date of my
signature, and may be revoked in writing at any time before my records are disclosed.

__________________________________________________
SIGNATURE OF APPLICANT

NHSC LRP Forms

____________________
DATE

C4