NIFA-06-10 Certifications for Application

Name:

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)	National Institute of Food and Agriculture US Department of Agriculture NIFA-06-10 OMB No. 0524-0047
Certifications for Application
NIFA Veterinary Medicine Loan Repayment Program

Instructions: Please print, sign and mail this form with your application.

Section 1. Certification by Applicant/Borrower

I hereby apply to enter into an agreement with the Secretary of USDA for repayment of the educational loan listed in my application, incurred solely for the costs of education, including reasonable living expenses, of attending a college of veterinary medicine accredited by the AVMA Council on Education. I hereby certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of the omission. I am aware that any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986. I hereby authorize the lending institution, servicing agent, and/or institutional program named in my application to release information about my loan or any loan owned, serviced, or administered by my lending institution, servicing agent, or program administrator to the administrators of the NIFA Veterinary Medicine Loan Repayment Program (VMLRP) and other authorized Government officials. This authorization shall remain in effect during my application and participation in the NIFA VMLRP, and 120 days after completion of VMLRP contracted service or 18 months after the Secretary determines I am in breach of this agreement, whichever is applicable.

Print Name		Signature		Date

Section 2. Application’s Certification of Accuracy of Information Provided

I certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information given may be investigated and that any false representation is sufficient cause for rejection of this application, or, if awarded loan repayment, that I am liable for return of all awarded funds and , further, that any false statement may be punished as a felony under 18 U.S.C. § 1001. I am aware that any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986. I authorize any program to which I owe a service obligation to release information about that obligation to administrators of the NIFA VMLRP and other authorized Government officials.

Print Name		Signature		Date

Section 3. Applicant’s Request for Confidential Recommendations

I certify that I am requesting recommendation(s) from individual(s) of my choosing that will be included in my NIFA VMLRP application. My application, including the completed recommendation forms submitted by my recommenders, will be used by NIFA officials to determine my eligibility for participation in the VMLRP. I understand that the recommendation(s) I am requesting shall be held in confidence and protected from disclosure by officials of the NIFA VMLRP according to Privacy Act System of Records (see Confidentiality and Privacy Act Notice in this application package). I authorize administrators of the NIFA VMLRP and other authorized Government officials to contact the individual(s) I have identified to request and additional information that may be needed in determining my eligibility for participation in the VMLRP.

Print Name		Signature		Date

Public reporting for collection of information is estimated to average 15 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of information. 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 valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to NIFA, OEP, 800 9^th St. SW, Washington, DC 20024, Attention Policy Section. Do not return the completed form to this address.

NIFA Form 06-10

OMB No. 0524-0047

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