Form NIFA-04-10 Loan Application Information

Name:

	NIFA Veterinary Medicine Loan Repayment Program (VMLRP)	National Institute of Food and Agriculture US Department of Agriculture NIFA-04-10 OMB No. 0524-0047
Loan Information Form
NIFA Veterinary Medicine Loan Repayment Program
Instructions: If you have qualified loans with different loan servicers, you need to complete a separate form for each loan servicer. If all of your loans have been consolidated into one loan account, you need only submit one Loan Information form. The information you provide in this form will be sent to the lending institution for the purposes of verifying the loan type, balance, payment amount, principal and interest, loan purpose, and repayment status, including deferment, grace, and forbearance status. Important: The completion of this form requires accurate and comprehensive information. We recommend that you gather your educational loan information before starting this form. You are required to complete Sections 1-3 and mail the form(s) prior to the application deadline. For additional information on qualifying loans, visit the VMLRP website (www.nifa.usda.gov/vmlrp).
Section 1. Loan Information

Applicant’s Name:			Social Security Number:
Name of Lending Institution:			Loan Account Number:
Name of Servicing Agent (to where payments are sent):
Address to where payments are sent:

Section 2. Loan Details and Repayment Information

Original Amount of Loan:				Date of Loan Disbursement:
Payoff Balance:				Date payoff is valid through:
Is this loan consolidated with another individual?	 Yes  No			Current Interest Rate of Loan:
Type of Loan:				Purpose of Loan:
Are you currently repaying the loan?		 Yes  No			If no, is the loan in deferment or forbearance status?		 Yes  No
If this is a consolidated loan, were the underlying loans ever past due or delinquent?		 Yes  No  Not Applicable			Are your payments up to date?		Yes  No

You are also required to mail us supporting loan documents (Promissory Note, Account Statement, and NSLDS reports) for each loan. Please refer to the Loan Document tutorial at the VMLRP website (www.nifa.usda.gov/vmlrp) for a detailed explanation on the required loan documents.

If you consolidated your veterinary school loans with other educational loans (e.g. undergraduate), you must provide a complete history of your student loans from the National Student Loan Database System (NSLDS). The NSLDS website can be found at www.nslds.ed.gov. There is also a section on the VMLRP website that explains how your loan consolidation may affect your eligibility and award level for the VMLRP.

Section 3. Certification by Applicant/Borrower

I hereby apply to enter into an agreement with the Secretary of USDA for repayment of the educational loan listed above, incurred solely for the costs of education, including reasonable living expenses. 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, fraudulent, or fictitious 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 and/or servicing agent named above 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 VMLRP, and to 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.

Signature (sign your full name in ink)		Date

Section 4. Certification by Lending Institution/Servicing Agent

Instructions: Please verify the information in Sections 1-3; make any corrections next to the item(s) in question. Complete Section 4 and return this form by US Mail to NIFA/DAS (Lisa Stephens), Room 3331, Waterfront Centre, 800 9^th St. SW, Washington, DC 20024. Call (202) 570-7410 if you have questions about completing this form.

Lending Institution/Serving Agent’s Certification

The undersigned states that, to the best of his/her knowledge, the loan identified above is a bona fide legally enforceable institutional, State, or Government education loan made for the purpose of meeting the borrower(s) costs of attending an accredited college or university of Veterinary Medicine, and that the information provided in sections 1-3 is correct. Or, I have indicated in sections 1-3 the corrections needed next to the item(s) in question.

Name and Title of Authorized Official for Lending Institution (Please Print)		Phone Number

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Federal Tax Identification Number/EIN (required for sending payments)

Signature		Date

Public reporting for collection of information is estimated to average 45 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 04-10

OMB No. 0524-0047

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