Application Part 2_Financial_AIedits

NIFA Veterinary Medicine
Loan Repayment Program (VMLRP)

National Institute of Food and Agriculture
US Department of Agriculture
OMB No. 0524-0050
Form Approved For Use Through XX/XX/XXXX

APPLICATION PART 2: FINANCIAL
NIFA Veterinary Medicine Loan Repayment Program

Instructions: You are required to complete Sections 1-3 below for each loan servicer you have outstanding loan debt
with. All loans must be listed for each servicer. If you have loans with different loan servicers, you need to complete a
separate form for each servicer. If your loans have been consolidated into one loan account, only submit one Application
Part 2 Financial form for the servicer of the consolidated loan.
Important: The completion of this form requires accurate and comprehensive information as of the time of submittal.
We recommend you gather your educational loan information before starting this form. Email the form(s) packet to
[email protected] or fax to (833) 208-8205 according to the instructions detailed in the Request for
Application prior to the deadline. For additional information to prepare your loan documentation, visit the VMLRP website
(https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-generalinformation).

Section 1. Loan Information
Applicant’s Name:
Name of Loan Servicer:
Loan Servicer Account
Number:
Address to where
payments are sent:

Section 2. Loan Details and Repayment Information
Original Total Amount of
Loan(s):
Total Loan Balance as of
Submittal Date:
Are you currently repaying the
loan(s)?

 Yes
 No

If no, are the loans in deferment or
forbearance status?

 Yes
 No

Are your payments up to date?

 Yes
 No

Does this loan information include a
consolidated loan?

 Yes
 No

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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.

Is this loan consolidated with
undergraduate loans?

 Yes
 No

If this is a consolidated loan, were
any loans past due or delinquent
prior to consolidation?

 Yes
 No
 Not Applicable

You are also required to include within your submittal supporting loan documentation as identified within the RFA. Please
refer to the Loan Document tutorial at the VMLRP website under Applicants (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 include the
details of your undergraduate student loans within your submittal as described within the RFA. There is a section on the
VMLRP website explaining how your loan consolidation may affect your eligibility and award level for the VMLRP.

Section 3. Certifications by Applicant/Borrower
Applicant/Borrower
☐I hereby apply to enter into an agreement with the U.S. Secretary of Agriculture for repayment of the educational loan listed above,
incurred solely for the costs of education, including reasonable living expenses. I hereby certify 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 information false,
fraudulent, or fictitious because of the omission. I am aware 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 from the date of submittal of my application and
throughout my participation in the NIFA VMLRP, up to and including 120 days after completion of my VMLRP agreement service.
Certification of Accuracy of information Provided
☐I certify 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, fictitious, or fraudulent because of the omission. I understand the information
provided may be investigated and any false representation is sufficient cause for rejection of this application, or, if awarded loan
repayment, I am liable for return of all awarded funds and, further, any false statement may be punished as a felony under 18 U.S.C. §
1001. I am aware 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 authorize any program to which I owe a service obligation to
release information about that obligation to administrators of the NIFA VMLRP and other authorized Government officials.

Signature of Applicant (certified electronic or scanned ink)

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 data 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, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention
Policy Section. Do not return the completed form to this address.

OMB No. 0524-0050
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NIFA invests in and advances agricultural research, education, and extension and promotes transformative discoveries that solve societal challenges.
USDA is an equal opportunity lender, provider and employer.