Form 10-XXX Specialty Education Loan Repayment Program (SELRP) - Ser

OMB Control No: 2900-0879
Estimated Burden: 15 min
Expiration Date: __/__/2023

SPECIALTY EDUCATION LOAN REPAYMENT PROGRAM
SERVICE OBLIGATION PERIOD COMPLIANCE VERIFICATION
AND LOAN REPAYMENT VERIFICATION FORM

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore, we may not conduct or
sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete
this form will average 15 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out the form. Participation in this program is voluntary, but
failure to provide complete and accurate responses on the application may impact your selection to participate in and receive the benefits of the program.

Privacy Act Notice: The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 in order for VA to determine your eligibility to receive
an education debt reduction payment award. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for:
civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the
administration of VA training, scholarship and education reduction programs, including verification of your eligibility to participate; and personnel administration. You do not have to
provide this information to VA; but if you do not, VA may be unable to process your request for consideration in this program. If you give VA your social security number, VA will use it
to obtain information relevant to determining whether to grant a loan repayment program award and to administer your education loan repayment, if awarded. It also may be used for other
purposes authorized or required by law.

PART I – EMPLOYEE INFORMATION
EMPLOYEE NAME:

EMPLOYEE OCUPATION:

DEGREE FOR WHICH SELRP WAS AWARDED:

SELRP PROGRAM STATUS:

VA MEDICAL CENTER:

SERVICE TERM START:

SERVICE OBLIGATION PERIOD:

SERVICE PERIOD START DATE:

SERVICE TERM END:
SERVICE PERIOD END DATE:

AMOUNT OF AWARD APPROVED FOR THIS SERVICE PERIOD (as noted on SELRP Agreement):

The SELRP participant identified on the attached roster is scheduled to complete the Service Period (SP) as noted in the SP End Date row. In
compliance with the SELRP Handbook, the SELRP coordinator will verify if any changes listed in the below section have occurred during the
service period and take the appropriate steps to notify Education Loan Repayment Services office of the changes needed to the participants record.
CHANGES DURING THE SERVICE PERIOD
Select the appropriate choice and use the award amount calculator to determine the prorated award amount or new service period end date if
applicable. If the employee was terminated or received a sustained a disciplinary action, they are not entitled to a prorated award amount and will
be removed from the program. If there are no changes move to the next part of the form.
CHANGE

SUPPORTING DOCUMENT

RESIGNATION

SF-50

DECEASED

SF-50

POSITION CHANGE (change to non SELRP
position)

SF-50

EMPLOYMENT STATUS CHANGE (change in
hours from full-time to part time, intermittent, NTE
appointment, detailing from position or occupation for
which SELRP award was made, etc.)

SF-50

TRANSFERRED TO ANOTHER VA (gaining
facility will need to process the prorated award if
applicable)
AUTHORIZED

ADJUSTMENT CALCULATOR (PLACE HOLDER)

SF-50

UNAUTHORIZED

NON-PAY STATUS (LWOP, AWOL, Active Duty)

Leave used summary

PERFORMANCE (employee's performance rating is
less than fully successful, see definitions)

Performance Rating

CONDUCT (received sustained disciplinary action
during SP)

Sustained action notice

NO CHANGES

N/A

N/A

Verify updated Service Period Information based on changes reported above.
UPDATED SERVICE PERIOD INFORMATION DUE TO A CHANGE DURING THE SERVICE PERIOD
SERVICE PERIOD NUMBER:

START DATE:

REVISED END DATE:

PRORATED AWARD AMOUNT:

Before the participant is reimbursed for the SP, the coordinator must verify the following:
1. Verify the employee's SP information is correct as noted on the SELRP Agreement.
2. Fiscal service has verified the payments made during the service period and the amount the participant is to be reimbursed, not to exceed what
is listed in the award approval column.
VA FORM
JUL 2020

10-XXX

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PART II – EMPLOYEE CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION
I have verified the information for my service period and authorize Fiscal Service to verify/validate the loan payments made by me during this service
period. I certify that all my statements are true, correct, complete, and made in good faith, and the documents and payment amounts I've provided from
my lender to support my SELRP reimbursement are for those student loans for which the original SELRP award was granted. I understand that false
statements or misrepresentation in this loan repayment transaction may be punishable by fine or imprisonment under Federal statute.
EMPLOYEE SIGNATURE:

DATE:

PART III – SELRP COORDINATOR VERIFICATION
This is to verify that the participant maintained an acceptable level of performance and conduct during the service period in the position for which
the SELRP was awarded. I have reviewed this form for accuracy and completeness prior to submission to Fiscal Service. When form is completed
by all parties, I will return this document to HCSS no later than the suspense date identified above.
SELRP COORDINATOR SIGNATURE:

DATE:

PART IV – FISCAL SERVICE LOAN PAYMENT VERIFICATION
I certify that (insert participants name) provided acceptable documentation/payment records from his/her lender(s) indicating payments were
made DURING the service period for which the educational loans/debt were approved under SELRP (as noted part I ).
(Col A) Amount Authorized from Part I

(Col B) Amount Employee Paid to Lender as
verified by Facility Fiscal Officer

MEDICAL CENTER CHIEF FINANCIAL OFFICER SIGNATURE:

(Col C) Amount Not Used
(Col A minus Col B)

DATE:

Note 1: Any resignations, terminations, transfers, or any other changes impacting the SELRP award should be addressed prior to making any
reimbursement payment to the employee. Failure to do so may result in over/underpayment and require corrective actions, including but not
limited to bill of collections proceedings.
Note 2: All periods of non-pay status not previously accounted for should be addressed for amendment of SP dates prior to making any
reimbursement payment to employee.
Definitions
Service Period. A service period is the period of time that an SELRP participant must serve in a paid duty status in order to receive an SELRP payment. A service
period is typically 12 months. Payments are made at the conclusion of a service period. A participant in the program may not receive debt reduction payments for
more than five consecutive 12-month periods of service in a paid duty status. The first, and in some cases the only, service period begins on the calendar day after a
VA Form 10-0349B is completed. Participants are ineligible to receive debt reduction payments any time that they are in a non-pay status. A service period is May
31, 2012 VHA HANDBOOK 1021.01 5 extended by the length of time that a participant spends in a non-pay status since that time must be made up with paid
service before an SELRP payment is made to the participant. The participant's service period will be extended by 1 calendar day for each increment of 8 hours of
leave without pay (LWOP).
Resignation/Early Termination*. As required by the SELRP policy, a participant will be terminated from SELRP if he or she vacates the position for which SELRP
was awarded (e.g., unauthorized transfer, resignation, realignment; or converts to a Title 5 appointment, etc.) before completing a 12-month period of paid service.
Early Termination: He or she is separated due to a staffing adjustment or reduction in force before completing a service period.
Position Change. He or she vacates the position for which SELRP was awarded and they are now in a non- SELRP position.
Employment Status Change. He or she had a change in hours from full-time to part time, intermittent, NTE appointment or detail from position or occupation for
which SELRP award was made, etc.
Facility Transfer. An SELRP participant may request to transfer his/her SELRP award eligibility to another VHA facility under the following conditions.
a. The SELRP award transfer request is initiated at least one month prior to the employee's transfer;
b. The SELRP applicant is transferring to the same/like position for which SELRP funding was awarded (i.e., a Staff Nurse transferring to another Staff Nurse
position); and
c. The gaining facility must have had the employee's position/occupation listed on their local SELRP announcement as difficult to recruit and/or retain prior to
the individual's request for transfer.
Non-Pay Status. Participants are not able to receive debt reduction payments for time that they are in a non-pay status. The time that a participant spends in a nonpay status (LWOP) during a 12-month service period covered under an SELRP Agreements, must be made up with paid service before a payment can be made to
the participant. For the purposes of SELRP, the service period will be extended by one calendar day for each eight hours of leave without pay or absent without
leave.
Acceptable Level of Performance/Conduct. An annual performance rating of “fully successful” or higher, or a proficiency rating or report of “satisfactory,” “fully
successful,” or higher constitutes an acceptable level of performance for an SELRP participant. A participant who receives an annual performance rating of less than
“fully successful,” or a proficiency rating or report of less than “satisfactory” or “fully successful”, or a sustained formal disciplinary/adverse action during an
SELRP service period is not eligible to receive an SELRP award.

VA FORM 10-XXX, JUL 2020

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