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Loan Repayment Programs
866-849-4047 | [email protected]

OMB No. 0925-0361
Form Approved for use through X/X/X

IC Recommendation for LRP Funding
NIH 2674-5
LRP Tracking Code:

Applicant's Identifying Information
Applicant Name:
Social Security Number:
Type of LRP:
Contract length (to commence
on program eligibility date):
Position Information
Title
Pay Plan/Occupational Series:

SelectTitle
Title
Select

Other:

SelectPay
PayPlan
Plan
Select

Grade (if appropriate):
NIH Salary at Program $
Eligibility Date:

Note: Please provide the applicant's basic NIH salary as of the
applicant's program eligibility date*. For applicants employed
under the Commissioned Corps, salary comprises base pay plus
quarters, subsistence, and variable housing allowances. Special
and bonus pay, such as board-certified, contract, and variable
incentive pay, are not included. Similarly, for applicants under the
General Schedule pay plan, Physicians Comparability Allowances
(PCA) are not included in the salary calculation. However,
pursuant to 5 CFR § 595.105(e), an individual receiving a PCA
who is accepted into the LRP must have his/her PCA reduced by
the amount of the loan repayment upon entry to the LRP.
* The program eligibility date is the receipt date of an application
in the Division of Loan Repayment or the EOD date for new
hires, whichever occurs later.

Personnel Documentation

Type of Assignment:

SelectOne
One
Select

Permanent
Temporary

Note: The applicant's NIH Salary needs to be supported by faxing
this documentation to the NIH Division of Loan Repayment at 1866-849-4046. Please use the Fax Coversheet that is provided
when you click "Submit" on this form to submit the required
documentation.

Start Date of Assignment from
SF50/SF52:

Month

Day

Year

End Date / Not to Exceed Date
from SF50/SF52:

Month

Day

Year

Can the assignment be
extended?

Yes (or N/A)
No

Instructions: After printing this application, please coordinate
the clearance process by obtaining the necessary signatures.
Incomplete applications will be returned to the LRPC.
Completed applications from LRPC's in support of renewal and
new applicants are due March 1 and May 1, respectively. If
you have any questions about completing this form, please call
the Loan Repayment Program at 1-866-849-4047.

NIH Form 2674-5
Privacy Act 09-25-0165

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