IHS Loan Application

Indian Health Service Loan Repayment Program

Documents and Forms

Document Name Document Type
Form 0917-0014 IHS Loan Application Form and Instruction
0917-0014 Educational and Professional Background IHS Loan Repayment Application - Educational and Professional Background.pdf www.ihs.gov/loanrepayment/applynow/ Form and Instruction
0917-0014 Financial Information IHS Loan Repayment Application - Financial Information.pdf www.ihs.gov/loanrepayment/applynow/ Form and Instruction
0917-0028 General Applicant Information IHS Loan Repayment Application - General Applicant Information.pdf www.ihs.gov/loanrepayment/applynow/ Form and Instruction
60 Day FRN for OMB No. 0917-0014, 02-05-2015.docx 60 Day Federal Register Notice for 0917-0014, Loan Repayment Program IC Document
60 day FR Publication 04-28-15 (2).pdf 0917-0014, Published 60 Day Federal Register Notice, Loan Repayment Program IC Document
FINAL 30 Day FRN for OMB No 0917-0014 05-27-15- DRA Final - TCLAY.docx 0917-0014, 30 Day Federal Register Notice for Loan Repayment Program IC Document
30 Day Federal Register Notice for IHS Loan Repayment Program, June 11, 2015.pdf OMB No. 0917-0014, Published Federal Register Notice for Loan Repayment Program IC Document
FINAL_LRP_Supporting_Statement_6-22-15 DRA.docx Supporting Statement for OMB No. 0917-0014, Loan Repayment Program IC Document

Information Collection (IC) Details

IC Title:	IHS Loan Application	Agency IC Tracking Number:	0917-0014

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0917-0014	Educational and Professional Background	IHS Loan Repayment Application - Educational and Professional Background.pdf	http://www.ihs.gov/loanrepayment/applynow/	Yes	Yes	Fillable Fileable Signable
Form and Instruction	0917-0014	Financial Information	IHS Loan Repayment Application - Financial Information.pdf	http://www.ihs.gov/loanrepayment/applynow/	Yes	Yes	Fillable Fileable Signable
Form and Instruction	0917-0028	General Applicant Information	IHS Loan Repayment Application - General Applicant Information.pdf	http://www.ihs.gov/loanrepayment/applynow/	Yes	Yes	Fillable Fileable Signable

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,999	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,999	1,999
Annual IC Time Burden (Hours)	2,999	2,999
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
60 Day Federal Register Notice for 0917-0014, Loan Repayment Program	60 Day FRN for OMB No. 0917-0014, 02-05-2015.docx	06/22/2015
0917-0014, Published 60 Day Federal Register Notice, Loan Repayment Program	60 day FR Publication 04-28-15 (2).pdf	06/22/2015
0917-0014, 30 Day Federal Register Notice for Loan Repayment Program	FINAL 30 Day FRN for OMB No 0917-0014 05-27-15- DRA Final - TCLAY.docx	06/22/2015
OMB No. 0917-0014, Published Federal Register Notice for Loan Repayment Program	30 Day Federal Register Notice for IHS Loan Repayment Program, June 11, 2015.pdf	06/22/2015
Supporting Statement for OMB No. 0917-0014, Loan Repayment Program	FINAL_LRP_Supporting_Statement_6-22-15 DRA.docx	06/23/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.