ASLRP Renewal fillable

ASLRP RENEWAL – FORM‐FILLABLE VERSION 
INSTRUCTIONS 
Attorneys:  Complete Parts 1 and 2, then submit electronically (with one attachment consisting of scanned 
copies of your loan history) to your component HR Representative.  Save a copy for your records. 
The loan history must: 
 Reflect the 2016 ASLRP payment(s), even if that loan has been paid in full.
 Show your personal payments from January through December of the previous calendar year, not the
12 months preceding submission.  ALSRP awards are calculated on a calendar year basis.
 Be titled “Last Name, First Name – ASLRP Renewal Loan History”
Component HR Representative:  Review Parts 1 and 2, then complete Part 3. 
 Check to see if the packet is complete.
 Forward to the Executive Office (or equivalent) or authorized delegate for completion of Part 4 (final
validation).
 When complete, forward entire packet to OARM electronically (Attn:  Deana Willis,
[email protected]).
 Ensure loan history attachment is included.
 Retain a copy for your records.
PART 1:  PERSONAL AND ELIGIBILITY INFORMATION 
1. Last: ____________________     First: ___________________      Middle: _____________  Suffix: _____
Last Four SSN: _***‐**‐_____
2. Component/District (as of June 1, 2017): ____________________
   ☐Check box if you moved to a different component or District since you last requested ASLRP. 
Work Telephone: ____________________
Email: ____________________________________      
3. Did you incur any period of leave without pay or time not in a pay status since you last requested ASLRP?
☐No
☐Yes, Dates: ____________________
☐If absence was due to uniformed service or compensable injury, check this box and attach
orders/supporting documents to your loan history.  (scanned file)
PART 2:  LOAN AND ASLRP PAYMENT DISTRIBUTION INFORMATION 
1. Enter the number of qualifying federal student loans:
___________ 
2.  List your total Federal student loan indebtedness (estimated as of May 1, 2017) 
$ __________ 
Do not include private student loan debt.  Note that the $10,000 minimum does not 
apply to renewals.   
3. Enter your personal loan payments to qualifying Federal student loans from January 1,
$ __________ 
2016 – December 30, 2016.  Do not include FY 2016 ASLRP payments.
4. Enter your FY 2016 approved gross (before taxes) ASLRP payment
$ __________ 
5. Please check one of the boxes below and enter the appropriate information.
☐I hold a general schedule appointment under the excepted Federal service. 
As of December 31, 2016, I held the grade GS: _____    Step: _____ 
☐I am an Assistant U.S. Attorney paid under Title 28, USC.   
As of December 31, 2016, I held the grade of AD  _____ 
My base salary as of December 31, 2016 (not including locality pay) was: $ __________ 

6.

7.

If you graduated from law school in 2016, were your qualifying Federal student loan payments were
tolled for part of the year?  ☐No  ☐Yes
(Enter dates payments were tolled (mo/year):  _____/_____ to  ____/______
CURRENT LOAN INFORMATION/LOAN HISTORY:
 Complete the table below for each of your qualifying Federal student loans.
o If you have more than two loans, use the loan information continuation page to add
additional loans.
o The table must be completed for each loan, even if all loans are with the same lender.
 List loans in the order you wish the ASLRP payment to be issued.  Please note that your loan
agreement may direct the internal distribution of payments – you must personally insure that
ASLRP payments are applied only to qualifying federal student loans and not to private loans.
 Attach one scanned document (loan history) consisting of a letters, statements, or Internet
printouts from lenders or loan servicing organizations for each loan demonstrating that loan
payments are current, that the loan is in good standing, and:
o Showing your personal payments for the previous calendar year (January – December, not
the 12 months preceding this submission); and
o The distribution of any ASLRP payments issued to that loan. If your prior ASLRP payment
was applied to a loan that is now paid off, include that loan and show the ASLRP payment.

Amount owed: 
Date corresponding to 
balance above: 
Loan holder / Loan Servicing 
Organization: 

Loan 1 

Loan 2 

$ __________ 

$ __________ 

__________ 

__________ 

____________________ 

____________________ 

$ __________ per__________ 

$ __________ per __________ 

$ __________ 

$ __________ 

$ __________ 

$ __________ 

$ __________ 

$ __________ 

Enter the loan holder’s name, 
the address to which payments 
are sent, which may differ from 
the regular business address. 

Account Number / Loan 
Identification Number 
Provide complete information DOJ 
should list on the payment issued to 
your loan holder. 

Your regular payment 
amount and frequency (e.g., 
monthly, quarterly, annually) 
Amount you paid to this loan 
between January 1 and 
December 31, 2016. 
Net amount of ASLRP 
payment applied to this loan 
in 2016. 
Amount you will pay to this 
loan in 2017 

8. 

9. 

I have reviewed my payment history.  I confirm that I received my FY 2016 ASLRP payment and that it was 
applied only to qualifying Federal student loans (e.g., there were no distributions to private loans; the 
loan holder credited my ASLRP payment).   ☐No  ☐Yes   

If no, please summarize your corrective action and estimated date by which correction will be 
implemented below.  Additional ASLRP payments cannot be approved until proof of correction is 
provided to OARM; however, we will continue to process your request during the interim.  Once the error 
is corrected, contact Deana Willis ([email protected]).   

Additional Information:  Use this space to address any issues you need to raise to OARM’s attention. 

ATTORNEY CERTIFICATION: 
I certify that all the information I provided for ASLRP consideration is true and correct, and that I am not in 
default on any qualifying Federal student loans, whether or not listed here.  As part of this certification, I attest 
that: 
☐I have read and understand the Attorney Student Loan Repayment Program (ASLRP) policy. 
☐ I understand that the ASLRP is an agency incentive program, not an entitlement, and is subject to 
availability of funds as determined solely in the discretion of the Department of Justice. 
☐ I understand that ASLRP awards are subject to tax and withholdings, which are deducted before 
payment is issued to the loan holder. 
☐ I am aware of the eligibility requirements, the “matching funds” provisions, and the requirement to 
continue making personal payments toward my qualifying Federal student loans while participating in 
the ALSRP. 
☐ It is my responsibility to monitor my loan accounts and manage my personal payments to ensure the 
loan holder does not stop taking automatic debits based on receipt of ASLRP payments, or reallocate my 
automatic payments to non‐qualifying loans based on receipt of ASLRP payments (which impacts on 
future renewal). 
☐ I understand that the ASLRP is a supplement to, not a substitute for, my personal payments to 
qualifying Federal student loans. 
☐ I understand that accepting ASLRP funds triggers a three‐year service obligation to the Department of 
Justice and not to federal service in general, and that the Department may recoup all payments issued 
on my behalf (at the pre‐tax rate) should I fail to complete my service obligation. 
☐ I understand that I am required to remain compliant with the ASLRP policy and that failure to do so 
may impact on payment eligibility. 
☐ I acknowledge that periods of leave without pay or other periods in which I am not in a pay status 
(except absence due to uniformed service or compensable injury) do not count toward completion of my 
service obligation. 
☐ I have not been the subject of any substantiated misconduct, performance, or disciplinary actions 
since I was last approved for ASLRP funds. (For questions, contact Deana Willis, [email protected].) 
☐ I understand that I may be subject to administrative or disciplinary action, including but not limited to 
termination of the repayment incentive payments, if I provide false information. 

Digital Signature_____________________________  Date:  __________________ 

General
This information is provided pursuant to the Privacy Act of 1974 (P.L. 93-597).
Authority for Collection of Information
5 U.S.C § 5379
Purpose and Uses
The main purpose for collecting the information requested on this form is to establish the terms under which an
individual receives a student loan repayment benefit under the Attorney Student Loan Repayment Program. The
information collected will be used as a basis for payroll actions and to identify and validate qualifying Federal
student loans. Disclosure of identifiable information, including the truncated Social Security Number (SSN), may
be made to the Internal Revenue Service for tax withholding purposes, the Department of Agriculture for payroll
action, and to the Department of Labor for worker compensation claims, and to lending or educational
institutions to identify and validate qualifying Federal student loans. This information may also be used by the
Department of Justice for other lawful purposes including law enforcement and in the event of litigation. In
addition, these records, or information therein, may also be used within the Department of Justice for study
purposes, such as projection of staffing needs, and/or creation of non-identifiable statistical data for reports to
other Federal agencies and Congress.
Information Regarding Disclosure of Your Social Security Account Number
Disclosure of the truncated SSN is mandatory since it is the identifier used by the DOJ Office of the Inspector
General and Office of Professional Responsibility when reviewing candidates for awards. The use of the
truncated SSN is necessary because of the large number of present and former employees and applicants who
have identical names and birth dates, and whose identities can be distinguished only by the SSN. It is used
primarily to identify an employee's personnel, leave, and pay records and to relate one to the other. It also may
be used by the Department of Justice to identify and validate qualifying Federal student loans. The information
gathered through the use of the number will be used only as necessary in personnel administration processes
carried out in accordance with established regulations and published notices of systems of records.
Effect of Non-Disclosure
Provision of this information is voluntary; however, failure to do so may result in non‐selection or preclude issuance of 
payment. 

PART 3:  COMPONENT VERIFICATION 
Review LWOP status indicated in Part I, question 3.  Are LWOP status and dates correct?   ☐Yes or n/a ☐No 
If no, enter correct dates: __________ 
Was the applicant the subject of any administrative performance or disciplinary actions in the past 12 months?   
☐No ☐Yes 
If yes, then provide details in a separate attachment. 
Has the applicant engaged in substantiated misconduct in the past 12 months? ☐Yes  ☐No 
If yes, provide details in a separate attachment. 
Is base salary as of December 31, 2016 (without locality pay) in Part 2, question 5 correct? ☐Yes  ☐No 
If, no enter correct amount: $  __________ 
HR Representative’s Name: ___________________________      Email: _________________________      
Position Title: ____________________     Telephone: ____________________      
HR Representative Digital Signature:  ____________________________________  Date: __________ 

PART 4:  COMPONENT VALIDATION: 
I am the Executive Office (or equivalent) or an authorized designate of: _________________________________ 
 I certify that the attorney’s last performance evaluation was at least at the Fully Successful level under 
Part 430 of Title 5, CFR, or a similar level of performance under another applicable performance 
management system; or that the attorney has been with the Department less than one year and has not 
qualified for an evaluation. 

 I certify that the attorney meets the requirements to receive ASLRP (OARM will validate loan data). 

Name: _________________________    Date: ____________     Signature:  __________________________ 

Loan Continuation Page 

Amount owed: 
Date corresponding to 
balance above: 
Loan holder / Loan Servicing 
Organization: 
Enter the loan holder’s name, 
the address to which 
payments are sent, which 
may differ from the regular 
business address. 
Account Number / Loan 
Identification Number 
Provide complete information 
DOJ should list on the 
payment issued to your loan 
holder. 
Your regular payment 
amount and frequency (e.g., 
monthly, quarterly, annually) 
Amount you paid to this loan 
between January 1 and 
December 31, 2016. 
Net amount of ASLRP 
payment applied to this loan 
in 2016. 
Amount you will pay to this 
loan in 2017 

3
Loan _____ 

Loan _____ 
4

$ __________ 

$ __________ 

__________ 

__________ 

____________________ 

____________________ 

$ __________ per__________ 

$ __________ per __________ 

$ __________ 

$ __________ 

$ __________ 

$ __________ 

$ __________ 

$ __________