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

DOD EDUCATIONAL
LOAN REPAYMENT PROGRAM (LRP)
ANNUAL APPLICATION

CONTROL NO.

LOAN PROGRAM (X one)
OMB No. 0704-0152
OMB approval expires

ACTIVE DUTY LRP
HEALTH PROFESSIONALS LRP
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, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria,
VA 22350-3100 (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 U.S.C. 2171, Education Loan Repayment Program: Enlisted Members on Active Duty in Specified Military Specialties; 2173, Education
Loan Repayment Program: Commissioned Officers in Specified Health Professions; 16301, Education Loan Repayment Program: Members of Selected
Reserve; 16302, Education Loan Repayment Program: Health Professions Officers Serving in Selected Reserve with Wartime Critical Medical Skill
Shortages; 16303, Loan Repayment Program: Chaplains Serving in the Selected Reserve, and E.O. 9397, Social Security Number (SSN).
PRINCIPAL PURPOSE(S): In completing this form, you are requesting your Military Service to pay a portion of your student loan(s). The information you
provide will be reviewed by Military Service personnel record custodians to verify that you meet eligibility requirements. This form will then be forwarded to
the lender that you identify for verification of the loan amount and status. The form is returned to the Service finance office to make the annual payment to
your lender. Collected information is covered by the Applicable Military Service System of Records Notice (SORN) for the Official Military Personnel File or
Military Records Jacket. These links can be found at: http://dpclo.defense.gov/privacy/SORNs/component/DOD_Component_Notices.html.
ROUTINE USE(S): To the lender (Department of Education, U.S. Public Health Service, or other financial institution) you identify so that the loan amount
and status can be verified. The lender returns the completed form to your unit for additional processing. To the Internal Revenue Service for the purpose of
reporting taxable income, and to the credit reporting agencies to assist in the recovery of any improper payments made toward delinquent debts owed by a
beneficiary or former beneficiary. The DoD Blanket Routine Uses found at http://privacy.defense.gov/blanket_uses.shtml may apply to this collection.
DISCLOSURE: Voluntary. However, if the requested information is not provided, DoD will not be able to verify the loan amount or status and make the
annual payment you are requesting. Your Social Security Number (SSN) is used to ensure accuracy of data involving the specified individual applicant. If
you do not provide your SSN, processing of your application may be delayed.
OFFICIAL MILITARY PERSONNEL FILES:
Air Force: http://dpclo.defense.gov/privacy/SORNs/component/airforce/F036_AF_PC_C.html
Army: http://dpclo.defense.gov/privacy/SORNs/component/army/A0600-8-104B_AHRC.html
Army National Guard: http://dpclo.defense.gov/privacy/SORNs/component/army/A0600-8-104b_NGB.html
Navy: http://dpclo.defense.gov/privacy/SORNs/component/navy/N01070-3.html
Marine Corps: http://dpclo.defense.gov/privacy/SORNs/component/usmc/M01070-6.html
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)

N E E D S

D D

6 7

(2) SIGNATURE

(3) DATE SIGNED
(YYYYMMDD)

2. SERVICEMEMBER DATA (To be completed by Servicemember or Borrower (if parent loan incurred for Servicemember's education - see instructions))
a. NAME (Last, First, Middle Initial)

c. SOCIAL SECURITY NO.

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

d. TELEPHONE NO. (Include Area Code)
I authorize the release of my financial data by lender/holder to complete entries in Section 3.
g. DATE SIGNED
f. SIGNATURE
(YYYYMMDD)

e. E-MAIL ADDRESS

3. LOAN DATA (To be completed by loan servicing agency)
a. NAME ON THE LOAN (Last, First, Middle Initial)

b. ORIGINAL DATE OF PROMISSORY NOTE (YYYYMMDD)

c. ORIGINAL LOAN AMOUNT

d. LOAN

f. LOAN HOLDER NAME

g. LOAN HOLDER ADDRESS (Include ZIP Code)

i. LOAN IN DEFAULT (X one)
YES

OF

LOANS

e. LOAN ACCOUNT NUMBER

j. UNPAID PRINCIPAL BALANCE

k. OUTSTANDING BALANCE

n. TYPE OF LOAN (See Instructions)

o. LOAN INTEREST

h. TELEPHONE NUMBER
(Include Area Code)
l. IS THIS A CONSOLIDATED LOAN?

NO

m. FEDERAL TAX IDENTIFICATION NO.

YES

NO

(1) CAPITALIZED

(2) CURRENT YEAR

$

$

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

q. LENDER ROUTING NUMBER

r. 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)

DD FORM 2475, 20131216 DRAFT

(2) TITLE

(3) SIGNATURE

PREVIOUS EDITION IS OBSOLETE.

(4) DATE SIGNED
(YYYYMMDD)
Adobe Designer 9.0

4.a. ORIGINAL LOAN AMOUNT

b. CANCELLED AMOUNT

c. DISBURSED AMOUNT

d. DATE OF DISBURSEMENT (YYYYMMDD)

5. REMARKS

N E E D S

D D

6 7

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 or Borrower.)
2.a. - g. Servicemember or Borrower must complete. If the
Borrower is the parent and has a Parent Loan for
Undergraduate Students incurred for the Servicemember's
education, please ensure the Servicemember's full name
and last 4 digits of their SSN are provided in Section 5,
Remarks.
SECTION 3. LOAN DATA
(To be completed by loan servicing agency.)
3.a. Name as it appears on the promissory note.
3.b. - c. Self-explanatory.
3.d. Loan ___ of ___ Loans. A separate DD Form 2475
must be completed for each loan if Borrower 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 to be used to ensure payments
are applied to the correct amount.
3.f. - h. Identify the name, address, and telephone number
of the institution that currently services the loan. Please
list any additional contact information in Section 5,
Remarks.
3.i. Mark X in the appropriate box.
3.j. Self-explanatory.
3.k. Self-explanatory.
3.l. If multiple loans have been consolidated, mark (X)
"Yes"
or "No" indicating consolidating action.
3.m. Provide Federal tax identification number for tax
withholding.

DD FORM 2475 (BACK), 20131216 DRAFT

3.n. Type of Loan. Select from list below: The loan must qualify under the
Higher Education Act of 1965, Title 4, Parts B, D, 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).
NOTE: For eligible LRP participants - Parent Loans for Undergraduate
Students (PLUS) and Consolidated Loans are also eligible for repayment
under the LRP, as long as the loans were incurred for the Servicemember's
education. Since the loans may be in someone else's name and could
include loans incurred for individual's education other than the
Servicemember (such as a sibling or loans incurred for their own education),
it would be necessary to have the borrower complete Section 2 and include
information regarding the education for which the loans were incurred.
3.o. Self-explanatory.
3.p. Complete this block only if different than the one listed in 3.f. and 3.g.
3.q. Lender may not use a routing number as the payment address.
3.r. Self-explanatory.
SECTION 4. LOAN DATA (To be completed by loan servicing agency.)
4.a. Self-explanatory.
4.b. Amount cancelled after Origination Date of Loan.
4.c. Self-explanatory.
4.d. Date of each individual disbursement.
SECTION 5. REMARKS.
Use this section to enter additional information that will assist in processing
this application.
After completion and signature, please return form to the address listed in
Section 1.a.