Service Verification_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

SERVICE VERIFICATION
NIFA Veterinary Medicine Loan Repayment Program
Instructions: Complete below sections and return the completed form to NIFA via the Box account set up with your Grants
Management Specialist (GMS), email to [email protected], or fax to (844) 332-8008. With each quarterly service
verification submittal you are required to include your Microsoft Excel service log demonstrating the actual service hours
performed during the reporting service period. The requirements for the service log may be found here:
https://www.nifa.usda.gov/nifa-21-015-vmlrp-program-guidance-manual. A current account statement for your servicer
reflecting VMLRP loan payments to your account during a service year is required with every October service verification
submittal. This account statement may be requested more frequently as needed. Failure to enclose required service log or
account statement will delay payments to servicers on your behalf as well as reimbursement of tax payments.

Section 1. General Information
VMLRP Participant Name:
Shortage Type:

 Type I: Private Practice (minimum 80% time)
 Type II: Private Practice – Rural Area (minimum 30% time)
 Type III: Public Practice (minimum 49% time)

Shortage Identification Code:
Quarter of Service:

Section 2. Veterinary Service
Instruction: Please review the shortage nomination form, included with your award package, before answering the
following questions.
By checking “Yes”, you are certifying you worked under supervision or provided self-service during the service period
reported in Section 1, did not incur leave-without-pay preventing attainment of the minimum required hours (based on fulltime equivalent of 40 hours per week), and did not terminate employment during the service period reported in Section 1.
 Yes
 No
By checking “Yes”, you are certifying you have met your minimum % FTE time, working in the counties within your
applicable shortage situation, and with the required must serve/may serve species outlined within your applicable shortage
situation during the service period reported in Section 1.
 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.

Section 3. Certification of Services and Hours Provided

By signing this document, I certify the services I have provided under the VMLRP agreement I have signed comply with
applicable Federal, state and local laws, and to the best of my knowledge none of the services provided were illegal
veterinary services for which funding is prohibited by Federal law. I further certify the information provided herein
regarding services or hours provided under my VMLRP agreement is accurate to the best of my knowledge. I am aware that
any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties as identified in
U.S. Code, Title 18, Section 1001.

Clinic Name

Clinic Address, City, State, & Zip Code

Print Name

Signature (certified electronic or scanned ink)

Phone Number

Email Address

Date

Public reporting for collection of information is estimated to average 15 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.