Form 004_FLRP Loan Information and Verification Form

OMB #0915-0150
Expires: December 31, 2009

LOAN INFORMATION AND VERIFICATION FORM
DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
HEALTH RESOURCES AND SERVICES ADMINISTRATION
BUREAU OF CLINICIAN RECRUITMENT AND SERVICE (BCRS)
DIVISION OF APPLICATIONS AND AWARDS

FACULTY LOAN REPAYMENT PROGRAM
INSTRUCTIONS:
APPLICANT: Complete one copy of this form for each loan you are applying to have considered for repayment under the Faculty Loan
Repayment Program. To each form, attach a copy of the promissory notes or disclosure statements, and statements from the current holder
indicating your name, original amount borrowed, date of original disbursement, and type of loan. In addition, include a current account
statement showing your loan balance. The current account statement must be dated not more than 30 days before the postmark date of
FLRP application. 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 loan holder's name and full address.
Yes

No

9. Original Date of the Loan

____________________

10. Original Amount of the Loan ______________________
as of (date)

11a. Current Balance (Principal & Interest) $

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 the education costs that were consolidated into a new loan.
Please read page 15 of the Bulletin under item number 3 – 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.
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 identified above to the HHS and/or it’s contractors for the purpose of assessing and verifying the
amount and eligibility of the educational loan for payment under the Faculty Loan Repayment Program. 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

____________________
DATE

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 current OMB control number. The OMB Number for this project is 0915-0150 and expires December 31, 2009. Public reporting burden for
this collection is estimated to average 3 hours 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 this burden, to HRSA Reports Clearance Office, 5600 Fishers Lane, Room 1033, Rockville, Maryland 20857.