Form 10-255c Specialty Education Loan Repayment Program (SELRP) - Edu

OMB Control No: 2900-0879
Estimated Burden: 10 min
Expiration Date: XXX XX, 2023

SPECIALITY EDUCATION LOAN REPAYMENT
PROGRAM - EDUCATION LOAN 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 10 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.

SECTION A – TO BE COMPLETED BY APPLICANT
As an applicant, you are applying for an educational assistance award that is offered in accordance with SELRP Program provisions.
1. LAST, FIRST, MI

2. SSN
SECTION B – TO BE COMPLETED BY THE LENDING INSTITUTION

3. NAME OF LENDING INSTITUTION
4. PHYSICAL ADDRESS OF LENDING INSTITUTION
LOAN 1 ACCOUNT NUMBER:
IS THIS A CONSOLIDATED LOAN?
DATE OF LOAN

NO
YES
ORIGINAL AMOUNT

If yes, see note at end of form.
MONTHLY PAYMENT

IS LOAN IN DEFERMENT/FORBEARANCE?
YES
NO

CURRENT BALANCE

ANNUAL % RATE

HAS THIS LOAN BEEN REFERRED TO A COLLECTION
AGENCY OR PLACED IN DEFAULT STATUS?

If yes, include date deferment ends:

YES

NO

LOAN 2 ACCOUNT NUMBER:
IS THIS A CONSOLIDATED LOAN?
NO
YES
DATE OF LOAN
ORIGINAL AMOUNT

If yes, see note at end of form.
MONTHLY PAYMENT

IS LOAN IN DEFERMENT/FORBEARANCE?
YES
NO

DATE OF LOAN

NO
YES
ORIGINAL AMOUNT

ANNUAL % RATE

HAS THIS LOAN BEEN REFERRED TO A COLLECTION
AGENCY OR PLACED IN DEFAULT STATUS?

If yes, include date deferment ends:
LOAN 3 ACCOUNT NUMBER:
IS THIS A CONSOLIDATED LOAN?

CURRENT BALANCE

YES

NO

If yes, see note at end of form.
MONTHLY PAYMENT

IS LOAN IN DEFERMENT/FORBEARANCE?
YES
NO

If yes, include date deferment ends:

CURRENT BALANCE

ANNUAL % RATE

HAS THIS LOAN BEEN REFERRED TO A COLLECTION
AGENCY OR PLACED IN DEFAULT STATUS?
YES

NO

PROVIDE THE FOLLOWING IF LOAN(S) TRANSFERRED OR SOLD FROM ANOTHER LENDER OR SERVICER:
NAME OF LENDER/SERVICER
DATE OF TRANSFER
WARNING: Any person who knowingly makes a false statement or misrepresentation in this loan repayment transaction, bribes or attempts to bribe a Federal Official,
fraudulently obtains repayment for a loan under this statue, or commits any other illegal action in connection with this transaction is subject to a fine or imprisonment
under Federal statute. I have read this statement and understand its contents. I understand that to the best of my knowledge that the loan(s) identified above are legally
enforceable commercial, government or state educational loans and its purpose was to pay for the borrower’s cost to complete an educational degree.
SIGNATURE OF AUTHORIZED LENDING REPRESENTATIVE:

DATE:

I hereby certify to the accuracy of the above information and I apply to enter into an agreement with the Under Secretary for Health for an education loan repayment
award to reduce the amount of principle and interest owed on the education loan listed on this form. I attest that my health educational loan was incurred solely for
the purpose of paying for the costs of my education, and reasonable living expenses while attending school to obtain a degree for the position for which I am
applying and/or appointed.
SIGNATURE OF APPLICANT:

VA FORM
NOV 2020

10-255c

DATE:

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