Form 1 NC LRP Authorization to Release Information

OMB No. 0915-0140, Expiration 04/30/2017

NURSE Corps Loan Repayment Program

U.S. Department of Health and Human Services Health Resources and Services Administration

NURSE CORPS LOAN REPAYMENT PROGRAM (NURSE CORPS LRP) AUTHORIZATION to RELEASE INFORMATION

As a NURSE Corps Loan Repayment (NURSE CORPS LRP) applicant, I _, hereby authorize:

(print full name)

1. The HHS, and/or its contractors, to release the following information to the lenders/holders of my educational loans in order to determine my eligibility/qualifications to participate in the NURSE CORPS LRP, and to determine the eligibility of my educational loans for repayment under the NURSE CORPS LRP: my name, address(es), social security number, account number(s), account status, and other information necessary to identify me.

2. Any program or entity to which I owe a service obligation, or defaulted on a service obligation, to release information relating to that obligation to HHS and/or its contractors.

This authorization will take effect on the date that I sign this release form. If I become a participant in the NURSE CORPS LRP, this authorization shall remain in effect until the date my NURSE CORPS LRP obligation, including any extension of the obligation pursuant to a continuation contract has been fulfilled or this authorization is revoked by me in writing. If I do not become a participant in the NURSE CORPS LRP, this authorization shall remain in effect until September 30, 2017.

Signature of Applicant Date

Authorization to Release Information Form

This form authorizes HHS, and/or its contractors, to release information that identifies the applicant for purposes of obtaining the applicant’s educational loan information. It also authorizes any program to which the applicant owes a health professions service obligation to release information to HHS and/or its contractors.

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 currently valid OMB control number. The OMB control number for this project is 0915-0140. Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, 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 Officer, 5600 Fishers Lane, Room 14N39, Rockville, MD 20857.