IHS Loan Repayment Application

Indian Health Service Loan Repayment Program

Application
Handbook
How to Apply

Apply Here for
Financial Freedom

This booklet describes the Indian Health Service Loan Repayment Program
(IHSLRP) and explains the application process. Application forms are
included. If any changes should occur in the LRP program before contracts
become effective, prospective participants will be provided with revisions
to this booklet prior to the conclusion of any loan repayment agreements.
Please write or call the IHSLRP if you have any questions about the program
or the application process.
The information in this handbook is subject to change without notice. Please
refer to www.loanrepayment.ihs.gov for the most up-to-date information.

Dear Colleague,
Thank you for your interest in the Indian Health Service Loan Repayment Program (IHSLRP).
A career with Indian Health Service (IHS) is an opportunity for professional and personal fulfillment
— a chance to experience the rewards of working with an appreciative, underserved population
while living in some of the most beautiful areas of the country. The costs of a health professional
education are high, but IHSLRP can give you the financial freedom to pursue the future you’ve
envisioned for yourself: a career with purpose and a sense of mission, helping people who truly
need you, and doing it all with adventure in your life. It’s no wonder that health professionals
consider the Loan Repayment Program (LRP) to be one of the most significant benefits offered by IHS.
On behalf of the Indian Health Service, thank you for your interest in serving American Indian
and Alaska Native people.

Robert E. Pittman, R.Ph., M.P.H.
Rear Admiral, USPHS
Assistant Surgeon General
Director, Division of Health Professions Support

Privacy Act Notice
General
This information is provided to you in accordance with the Privacy Act of 1974 (Public Law (P.L.) 93-579), as you are supplying us with
information for inclusion in a system of records.
Authority
Section 108 of the Indian Health Care Improvement Act (P.L. 94-437), as amended by the Indian Health Care Amendments of 1992 (P.L. 102-573).
Program Administration
The Loan Repayment Program is administered at the Indian Health Service (IHS), Office of Public Health Support, Division of Health Professions
Support. The IHS is one of 11 agencies of the US Department of Health and Human Services (HHS).
Purpose and Uses
The purpose of the IHSLRP is to obtain health professionals to meet the staffing needs of the IHS in Indian health programs.
The information you supply will be used to evaluate your eligibility for participation in the LRP. Your application and related data are included
in a file to be used within HHS for record-keeping and participant management while you are in the program. The information may also be
disclosed in accordance with the Privacy Act and IHS Privacy Act Systems of Records 09-17-0002, disclosures to the public as required by the
Freedom of Information Act, to the Congress, the National Archives, the Bureau of Accounting Office, and pursuant to court order. Your name
(if awarded), the professional school you attend or have attended, and the date of graduation may be made available to health professions
associations and to groups who have responsibility for coordinating educational loan repayment funds paid to individuals from federal and
other sources, and to individuals and organizations deemed qualified by the Secretary of the US Department of Health and Human Services
to carry out such research.
Effects of Nondisclosure
Under the Debt Collection Act, you are required to disclose your Social Security number (SSN) if you are awarded loan repayment. If you do
not disclose your SSN, your application will be considered incomplete.
Discrimination Prohibited
Title VI of the Civil Rights Act of 1964, as amended, provides that no person in the United States (US) shall, because of race, color, or national
origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving
federal financial assistance.
Section 504 of the Rehabilitation Act of 1973, as amended, provides that no otherwise qualified handicapped individual in the US shall, solely
by reason of his/her handicap, be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program
or activity receiving federal financial assistance.

Contents
1 The IHS Loan Repayment Program

13 How to Apply

3  Are You Eligible?

15  About LRP Application Forms

3  What Is an Indian Health Program?

15  Application and Award Deadlines

3  How Are Participants Selected?

15  How to Reapply If You Are Not Selected

3  Award Distribution

15 How to Complete the Application

15  Using the Checklist

5 Qualifying Loans and LRP Payments

7  Qualifying Loans

16 Section 1: How to Complete the General Applicant
Information Section

7  Verification of Total Debt from Qualified Loans

7  Payments

17 Section 2: How to Complete the Educational
and Professional Background Section

7  LRP Payment Examples

18 Section 3: How to Complete the Financial
Information Section

8  Delinquency on the Repayment of Any Federal Debt

8  Loans Not Eligible for Repayment

18 Section 4: A Review of the Comparison of Benefits
Between Commissioned Corps and Civil Service
(Including Affidavit)

9 IHS Loan Repayment Service Obligation

18 Section 5: About the Sample Contract

11  Service

11  Matching to a Site

19 LRP Application Forms

11  Employment Options

21  Application Checklist

22  Section 1: General Applicant Information

24  Section 2: Educational and Professional Background

26  Section 3: Financial Information

27 Section 4: Comparison of Benefits Between
Commissioned Corps and Civil Service
(Including Affidavit)

30 Section 5: Sample LRP Contract

33 Recruiter Information

37  Recruiter Offices

38  IHS Discipline Representatives

The IHS Loan
Repayment Program

Apply Here for Financial Freedom

The IHS Loan Repayment Program
Are You Eligible?
All health professions are eligible to apply to the LRP. However,
the professions that are actually funded change each year
depending on Indian health program staffing needs. Please refer to
www.loanrepayment.ihs.gov for the current year’s priority list.
Applicants for the LRP must be health or allied health professionals who:
• Are US citizens;
• A
 re committed to practice at an IHS or other Indian health
program priority site;
• Sign a contract to practice at an Indian health program priority site;
• C an begin service on or before September 30 for two continuous
years of full-time clinical practice;
• Have a degree in a health profession*; and,
• Have a valid state license to practice in a health profession.
* Health professions eligible to apply: allopathic medicine and osteopathic medicine (various
specialties as needed), podiatric medicine, physician assistant, nursing, public health nursing,
dentistry, optometry, pharmacy, psychology, social work, environmental health, engineering,
an allied health profession, or other health professions as determined by need.

How Are Participants Selected?
IHS has created a ranking system to distribute LRP awards
with the utmost fairness. As the goal of the program is to fill
staff vacancies in Indian health programs, the ranking system
gives highest consideration to program staffing needs and
shortages of specific health profession disciplines. Once the
need is assessed, each site is ranked accordingly. Please refer
to www.loanrepayment.ihs.gov for the latest priority list.
Consistent with this priority, considerations in ranking applicants
include:
• A
 merican Indian/Alaska Native — IHS gives priority to applications
made by American Indians and Alaska Natives and to individuals
recruited through the efforts of Indian Tribes, Tribal or Indian
organizations.
• C urrent Service — Current LRP recipients requesting contract
extensions are given priority over new awards.
When all other factors are equal between applicants, additional
equal-weight factors are applied. Applicants who meet more of
the following factors than other applicants will be selected:
• Current employment in an IHS, Tribal or Urban program.
• Date of availability for service (first come, first served).

What Is an Indian Health Program?
For LRP purposes, the term “Indian health program” is defined in the
Indian Health Care Improvement Act (IHCIA) Public Law 94-437, as
any health program or facility funded in whole or in part by IHS for
the benefit of American Indians and Alaska Natives (AI/AN). These
health programs or facilities must be administered directly by IHS, by
any Indian Tribe or any Tribal or Indian organization contracted under
The Indian Self-Determination Act, the Buy Indian Act, or by an Urban
Indian organization pursuant to Title V of the IHCIA.

• Date the application was received by the LRP.

Applicants will be accepted into the LRP
according to the above priorities as long as
funds remain available during the fiscal year.

Award Distribution
Each year, funds appropriated for the LRP are distributed among the
health professions depending on health program staffing needs.



Qualifying Loans
and LRP Payments

Apply Here for Financial Freedom

Qualifying Loans and LRP Payments
Please refer to the Federal Register Notice for the current fiscal year
for any updates or changes to the benefits of the program.
Qualifying Loans
The LRP repays qualifying health professions education loans
as follows:
• U
 p to $20,000 per year for participants signing a two-year
service contract.
• T wenty percent of the federal income tax liability on the award
and additional FICA taxes, with payment made directly to the IRS.
• O
 nly the health professions education portion of consolidated
loans (health professions educational loans combined with
non-health professions education loans). Applicant must provide
copies of final statements from the original lending institution
at the time of the loan consolidation to determine the portion
eligible for repayment.
• Q
 ualifying loans are limited to government (federal, state, local)
and commercial loans used to pay for health professions schools.
• L RP pays directly to the participant the principal, interest, and
related expenses (including tuition, fees, books, lab expenses
and reasonable living expenses) incurred for qualifying health
professions educational loans.
Verification of the purposes for which the loan was obtained is
required for some loans. A number of federal program loans don’t
require verification since they already meet statutory requirements.
These include:
• Health Education Assistance Loan (HEAL) Program
• Guaranteed Student Loan (GSL) Program
• P
 erkins Loan, formerly National Direct Student Loan
(NDSL) Program
• Health Professions Student Loan (HPSL) Program
• Supplemental Loans for Students (SLS)
• Parent Loans for Undergraduate Students (PLUS) Loans
All other loans require lender verification, including loans from
undergraduate and graduate health professions schools.

Verification of Total Debt from Qualified Loans
When you are selected for participation in the LRP, copies of your
financial information Section 3 of the application are used to verify
total debt from your qualified education loans. Loan repayments will
begin once the contract has been signed by you and by the Secretary
of HHS or the Secretary’s IHS delegate, as provided in Section D of the
LRP Contract.
Payments
Letters of acceptance are sent on the last day of each month. If you
are already employed by IHS or another Indian health program, LRP
payments will begin within 120 days from the date the Secretary’s
delegate signs the contract. For new LRP recipients who are not
currently serving at an IHS facility, your payments begin 120 days
from your entry on duty date (same as contract date).
LRP Payment Examples
Example A
Participant with two-year service contract, $90,000 in qualified
education loans
The LRP paid $20,000 per year, which includes a payment of 20
percent of the income tax liability ($4,000 per year) made directly to
the IRS. The LRP also withheld the recipient’s portion of the FICA tax
($1,836) from the award amount, and paid the employer’s portion of
the FICA tax ($1,836). Total award to the participant over two years:
$36,328. The participant applied for a contract extension for additional
repayment funds.
Example B
Participant with two-year service contract, $30,000 in qualified
education loans
The LRP paid $15,000 per year, which includes a payment of 20
percent of the income tax liability ($3,000 per year) made directly to
the IRS. The LRP also withheld the recipient’s portion of the FICA tax
($1,377) from the award amount, and paid the employer’s portion of
the FICA tax ($1,377). Total award to the participant over two years:
$27,246.
Example C
Participant with consolidated education loan
A $12,000 loan for nonprofessional undergraduate education was
consolidated with an $18,000 loan for medical education for a
total loan balance of $30,000. Only the $18,000 loan for medical
education was eligible for repayment. The participant received
$18,000 (less applicable taxes), which covered the eligible portion
of the consolidated loan.



Indian Health Service Loan Repayment Program

Application Handbook

Delinquency on the Repayment of Any Federal Debt
If you are delinquent on the repayment of any federal debt, you
must provide documentation from your lender that you have either
negotiated a repayment schedule or that your federal debt is paid in
full. Your LRP payments could be garnished to satisfy delinquent debt
if you don’t negotiate a repayment schedule. Examples of federal
debt include:
• Delinquent federal income taxes
• Audit allowances
• Federally guaranteed (or insured) loans
• Federal-direct loans
• Other miscellaneous federal administrative debts
Loans Not Eligible for Repayment
Certain financial or service debts incurred under federal and state
programs are not eligible for repayment under the LRP. Examples
of these types of debts include, but are not necessarily limited to,
the following:
• Physicians Shortage Area Scholarship Program
• P
 ublic Health Service and National Health Service Corps
Scholarship Training Program
• IHS (P.L. 94-437, Section 104) Health Professions
Scholarship Program
• P
 ublic Health Service, National Health Service Corps
Scholarship Program
• A
 rmed Forces (Air Force, Army, Marines or Navy) Health
Professions Scholarship Programs
• L oans which may be repaid either in cash or by obligated service
(in deference to health professions loan programs and to prevent
conflicting obligations)
• Any loan that requires a service obligation
Also ineligible for repayment are:
• L oans from other than approved government and commercial
sources (e.g., loans obtained from private organizations, friends
and relatives).
• L oans or portions of loans obtained in pursuit of a different health
profession from the one in which you are hired for the program.
For example, if you obtain a professional degree in nutrition and
nursing and come to work at IHS as a registered nurse, only the
loans obtained in pursuit of the nursing education are eligible for
repayment, while those obtained for the nutrition training are not.



IHS Loan Repayment
Service Obligation

Apply Here for Financial Freedom

IHS Loan Repayment Service Obligation

Employment Options

Service

LRP participants are employed for their service periods under several
personnel systems:

LRP participants must serve their two-year contracted period in
an IHS-approved site. IHS annually ranks all Indian health program
sites in order of priority by position, with priority given to sites
with the greatest vacancy rates and need. Please refer to
www.loanrepayment.ihs.gov for the most recent priority listing.
Matching to a Site
Your selection for participation in the LRP is contingent on you
receiving an offer of employment at an approved LRP site and
agreeing to begin service there before the end of the fiscal year. Your
discipline-specific Public Health Professions (PHP) recruiter will work
with you to explore employment opportunities at IHS priority sites.

• S alaried appointments as commissioned officers in the
Commissioned Corps of the US Public Health Service
• G
 eneral schedule (GS) employees in the federal Civil Service
personnel system of IHS
• E mployee of a Tribal program conducted under an Indian
Self Determination Act (P.L. 93-638) contract (Tribal hire)
• E mployee of an Urban Indian program assisted under
Title V of the IHCIA
• Employee of a Buy Indian contract
Section 4 of this booklet contains full information on the Commissioned
Corps and the federal Civil Service personnel systems, as required by
law, so you can make an informed decision as to which service (if
applicable) you would prefer if accepted into the program. An affidavit
is included for you to sign, stating that you’ve been provided with and
have read this information on the two personnel systems used by IHS,
and that you understand the differences between the two.
You must maintain a satisfactory level of employee performance
at your approved site. Failure to meet these standards can result in
termination of employment and therefore cause a breach of your
LRP contract.

11

How to Apply

Apply Here for Financial Freedom

How to Apply
About LRP Application Forms
This booklet contains a complete set of LRP application forms. If you
need additional forms or booklets, or have any questions, please
contact the program at:
Indian Health Service
Loan Repayment Program
801 Thompson Avenue, Suite 120
Rockville, MD 20852

How to Complete the Application
This section takes you step-by-step through the LRP application.
When you are finished, please review your application carefully
before submitting. The checklist provided will assist you in
preparing your application, and you should submit it along with
your application. LRP applications must be complete and include
all required support documentation. Incomplete applications are
not eligible for consideration.
The application is composed of five sections:
Section 1: General Applicant Information

P: (301) 443-3396
F: (301) 443-4815

Section 2: Educational and Professional Background

www.loanrepayment.ihs.gov

Section 4: C omparison of Benefits Between Commissioned
Corps and Civil Service (Including Affidavit)

8:00 am-5:00 pm (EST), Monday through Friday (except federal holidays)

Section 3: Financial Information

Section 5: S ample LRP Contract (an official contract will be
sent to you if you’re chosen for an award)

Application and Award Deadlines
Applications are accepted all year, but are
processed for consideration from January through
September 30 each award year, or until all funds
are exhausted. The application deadline is the
Friday of the second full week of each month.
Successful applicants must begin their service
period no later than September 30 of the fiscal
year in which you’re accepted into the LRP.

How to Reapply If You Are Not Selected
You will be notified by mail by October 31 if you are not selected for
an LRP award. If you wish to reapply in the next LRP award cycle,
you are required to notify LRP in writing. Your application will be
kept on file and considered for all funding cycles.

Please pay special attention to the Section 3 forms which request
details of all qualified loans you want considered for repayment. If
you have more than one loan, complete a separate form for each
individual loan. Make copies of a blank form if you need more forms
than are provided. It is important that you submit all of these forms
along with your application, as no additional forms will be accepted
once an award is approved.
Complete all sections of the application and review the information
carefully before submitting. Mail the original forms, including the
completed checklist, and any required documentation to:
Indian Health Service
Division of Health Professions Support
Loan Repayment Program
801 Thompson Avenue, Suite 120
Rockville, MD 20852
Please retain a copy of the entire application for your personal records.
You will be notified by letter if you are approved for participation in
the IHSLRP, and an official contract will be sent to you.
Using the Checklist
The checklist is included to assist you in preparing your application
and to ensure that it is complete. Check off each item as you
complete it and gather the documentation required. Return the
completed checklist along with your completed application.

15

Indian Health Service Loan Repayment Program

Application Handbook

Section 1: How to Complete the General Applicant
Information Section
The first section of the application covers general applicant
information, including personal data, education information and
details of existing service obligations.
Line 1 — Name
Provide your full legal name — last name first, then first name and,
if applicable, middle name.

Line 8b — If you are not employed with IHS and have checked NO,
this line determines if you are employed in a program conducted
or assisted under certain federal laws and acts. Contact your
human resources department for assistance in determining the
status of your program.

• C heck the first choice if you are employed in a program
conducted under a contract entered into under the Indian
Self-Determination and Education Assistance Act (P.L. 93-638
as amended).

• C heck the second choice if you are employed in a program
assisted under Title V of the Indian Health Care Improvement
Act (IHCIA, 25 U.S.C. 1601)

• C heck the third choice if you are employed with a Buy Indian
Act Organization (25 U.S.C. 47)

Line 2 — Social Security Number (SSN)
Enter your SSN on line 2. If you don’t provide it on your application
and you are later selected for an IHSLRP award, you will be required
at that time to provide your SSN for purposes of payroll and payment
to you of IHSLRP benefits. This is a condition of your award.
Lines 3 and 4 — Home Address, Home Telephone and Email
Provide your full address, including apartment number if applicable,
on line 3. Enter your home phone number, including area code, and
your primary email address on line 4.

• S tandard Form 50B (SF-50B). SF-50B, also known as SF-50, is the
Notification of Personnel Action. If you have ever been employed
with the federal government, this form documents your service.

If none of these choices describes your employment, skip this line
and go on to line 9.
Line 9 — American Indian/Alaska Native

Lines 5 and 6 — Work/School Address and Telephone/Email
Provide your address at work or school, if applicable, on line 5. Be
sure to include any apartment, room or mail stop numbers. On line 6,
enter your work or school phone number, and your work/school
email address if you have one and it’s different from your primary
email address. If you do not have a work or school address, skip line 5
and 6 and go to line 7.
Line 7 — Date of Birth

IHS gives priority to applications made by American Indians and
Alaska Natives who are members of a federally recognized Tribe.
Submit a copy of an approved Bureau of Indian Affairs (BIA)
Certification Form 4432 with your application.
You must use BIA Certification: Form 4432, as follows:
A
 merican Indian: Category A — Members of Federally
Recognized Tribes, Bands or Communities
Alaska Native: Category D — Alaska Native

Provide your date of birth here (mm/dd/yyyy).
Line 10 — IHS Scholarship Recipient
Line 8 — Employment at IHS
If you are currently employed with IHS, check the YES box and go to
line 8a. If you are not currently employed with IHS, check the NO box
and go to line 8b.
Line 8a — If you are employed with IHS and checked YES, this line
requests details of your IHS employment. Check the appropriate
box if you are in the USPHS Commissioned Corps or a federal civil
service employee. Provide your entry date (the date you started
work with IHS) and the site or location where you are employed.
If you’re currently employed with IHS, provide employment
verification documentation, as applicable:

• IHS employment documentation (a letter from your employer
stating dates of employment, full- or part-time, job title, site
name and entry-on-duty date)

• T ribal employment documentation (a letter on Tribal
letterhead stating dates of employment, full- or part-time,
job title, site name and hire date)

• Commissioned Corps orders

16

IHS gives priority to applications made by former IHS Scholarship
recipients. Please submit a copy of your completion letter with
your application.
Line 11 — Existing Service Obligation
This line requests information on any existing service obligations you
might have. A service obligation is defined as required employment
for a period of time. If you have an existing service obligation as
defined here, check YES and go to line 11a. If you do not have an
existing service obligation, check NO and go to line 12.
Line 11a — If you checked YES, provide details of your existing
service obligation, including the program name and address, the
name and telephone number of a contact person and the terms
of your obligation. You are asked if you are in default of the
obligation — check the appropriate YES or NO box. Finally, enter
the date you will complete or existing service obligation.

Apply Here for Financial Freedom

Line 12 — Availability Date

Line 4 — Practice Experience

On this line, enter the date you will be available to begin work
under the IHSLRP. You must begin your service period no later than
September 30 of the fiscal year in which you’re accepted into the LRP.

Provide the details of your professional practice experience for the
past five years. If this does not apply to you, write “NA” on the line
and go to line 5.

Section 2: How to Complete the Educational
and Professional Background Section
This section is to be completed by graduates only, and details your
educational and practice experience, if applicable. Information
covered includes training and graduate programs, practice experience
and licensing. If any line does not apply to you, write “NA” (for “not
applicable”) on that line and go on to the next line.
Line 1 — Professional School
Provide the name of the professional school from which you
graduated and the school’s full address. Enter the year you graduated
or will graduate, and the degree you obtained.
Line 2 — Residency/Graduate Program Information
If you have completed a residency or graduate program, check the
YES box and go to line 2a. If you have not completed a residency or
graduate program, check the NO box and go to line 3.
Line 2a — This line requests specific information about your
residency or graduate program. Provide the year you completed
or will complete your residency, school or graduate program, the
name of the residency, school or graduate program, the address,
and the residency/program director’s name and phone number.
Line 2b — For physicians only, enter your specialty. Check the
appropriate box if you are board certified or board eligible. If you
are board certified, enter the year you will be re-certified. List your
sub-specialty if you have one.
Line 3 — Professional Training Locations
This line requests information about your professional training
locations. List each one separately. Provide program name and
address, and the name and telephone number for the program
director. If this does not apply to you, write “NA” on the line and
go to line 4.

As you describe your practice experience, include the following
information:
• Location(s) where you’ve practiced
• The nature of the population served
• Number of specialties in the practice
• Any hospital affiliations
• A
 llocation of clinical practice time to these specialties:
FP/GP, INT, OB/GYN, PED, PSYCH, ER
If you need more space to provide full information for line 4, please
use a continuation sheet. At the top of the page, write Section 2,
Line 4, Practice Experience, Continued, along with your name and
SSN. Attach the sheet to your application.
Line 5 — Last Work Site (If IHS, Tribal or Urban)
For the last site where you worked, provide your job title, the name
of the site director or other official, the site address and telephone
number of the director or official. If this does not apply to you, write
“NA” on the line and go to line 7.
Line 6 — Practice Time Allocation
On this line, enter the current percent of your practice time
that is office-based and hospital/clinic-based, and/or spent in
administration and teaching. If this does not apply to you, write “NA”
on the line and go to line 7.
Line 7 — Professional References Information
Provide a minimum of three professional references, including name,
position or title, address and telephone number. This information will
be kept confidential.

17

Indian Health Service Loan Repayment Program

Application Handbook

Section 3: How to Complete the Financial Information Section
This section requests details of qualified loans you want considered
for the LRP. If you have more than one qualified loan, complete
Section 3 forms for each individual loan. Submit copies of loan
and payment documentation (current statements) that have the
following identifying information: SSN, name and address.

Section 4: A Review of the Comparison of Benefits Between
Commissioned Corps and Civil Service (Including Affidavit)

Line 1 — Lending Institution/Program

In accordance with Public Law 100-713, Section 108(c)(1), which
requires that the Indian Health Service (IHS) provide information on
both the Commissioned Corps and Civil Service personnel systems,
we ask that you read the attached information. The information
will assist you in making an informed decision as you consider
employment with the IHS.

Provide the name and address of the lending institution or the
federal or state program from which you have obtained the loan that
you wish to be considered for repayment.

After you have reviewed the personnel systems information,
please sign, date and return the affidavit as part of your
completed application.

Line 2 — Date of Loan

Section 5: About the Sample Contract

Enter the date the loan was originated (mm/dd/yyyy).

This section is a sample Loan Repayment Program Contract. You
will receive an official copy to sign and return if you are selected
for an award. When you sign the contract, you will be agreeing to
a service obligation to provide full-time clinical service in an Indian
health program for two years for new recipients, or one year for
extensions. Please read the sample contract thoroughly so that you
fully understand all provisions. If you have any questions regarding
the contract, call the LRP office at (301) 443-3396.

Line 3 — Original Loan Amount
Enter the original amount of your loan. This is not the current balance
(see line 4).
Line 4 — Current Loan Balance
Enter the current balance of your loan and the date of the balance.
Line 5 — Payment Amount
Enter the amount of your regular loan payment.
Line 6 — Deferment of Loan
If your loan is in deferment, check the YES box and enter the date
the deferment ends.
Line 7 — Loan Annual Percentage Rate (APR)
Enter the annual percentage rate (APR) of your loan.
Consolidation of Undergraduate and Graduate Educational Loans
IHSLRP pays for education costs for only one health professions
degree. If you have consolidated your graduate and undergraduate
loans into one loan, LRP will make a determination of what portion of
the consolidated loan will be repaid for successful applicants. Attach
a copy of the loan documents for the health professions loan that
was consolidated into the new loan, along with a copy of your
current statement that includes your SSN, your name and address.
Line 8 — Certification by Applicant
This line asks you to sign to certify the accuracy of the information
you are providing in Section 3 of the application. Sign your full name
in ink and enter the date.
Line 9 — Certification by Lender
This line asks your lender to sign to certify the accuracy of the
information provided in Section 3 of the application.

18

Indian Health Service Loan Repayment Program

Application Handbook
FORM APPROVED
OMB Approval No. 0917-0014
Exp. Date XX/XX/XX11

Department of Health and Human Services
Public Health Service
Indian Health Service Loan Repayment Program
Application for the Indian Health Service Loan Repayment Program

Section 1: General Applicant Information
Estimated Average Burden Time to Complete the Application Form:
Public reporting burden for this collection of information is estimated to vary from 60 to 120 minutes per response with an average of
90 minutes per response, 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 currently 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: Indian Health Service, Reports Clearance Officer, Attn: PRA (0917-0014), 12300 Twinbrook Parkway, Suite 450, Rockville, MD, 20852.
Do not mail completed forms to the above address.
Mail completed applications to: IHSLRP, 801 Thompson Avenue, Suite 120, Rockville, MD 20852
(Only complete applications will be considered.)
PERSONAL INFORMATION
1. Name_ _____________________________________________________________________________________________________

Last

First

Middle

2. Social Security Number________________________________________________________________________________________
(Applicants may choose to provide their SSN on a voluntary basis. Should you be awarded an IHSLRP award, you will be required at that time
to provide your SSN for purposes of payroll and payment to you of IHSLRP benefits as a condition of your award.)

3. Home Address_______________________________________________________________________________________________

Number

Street

Apt. #

_____________________________________________________________________________________________________________

City

State

ZIP Code

4. Home Telephone_____________________________________ Email___________________________________________________
5. Work/School Address_________________________________________________________________________________________

Number

Street

Apt. or Room #

_____________________________________________________________________________________________________________

City

State

ZIP Code

6. Work/School Telephone_______________________________ Email (if applicable)_ ________________________________________
7. Date of Birth (mm/dd/yyyy)_ _____________________________________________________________________________________

22

Apply Here for Financial Freedom

Section 1 (continued)
8. Are you currently employed with IHS?

Yes

No

8a. If YES:

Please submit employment verification with application

Current IHS employment is with

Entry Date __________________________________________ Site/Location ____________________________________________

Commissioned Corps

Civil Service

8b. If NO:

Is your current employment with: (If you check any, you must submit employment verification with your application)

A program conducted under a contract entered into under the Indian Self-Determination Act

A program assisted under Title V of the Indian Health Care Improvement Act

A Buy Indian Act Organization

9. Are you an American Indian or Alaska Native?

Yes

No

(If YES, please submit BIA Form 4432 with your application)

10. Are you an IHS Scholarship recipient?

Yes

No

(If YES, please submit a copy of your completion letter with your application)

11. Do you have an existing service obligation?

Yes

No

(For the definition of existing service obligations, see the LRP handbook “How to Apply for your Financial Freedom,” Section 1, page 16, instructions for Line 11.)

11a. If YES:

Name of Program____________________________________________________________________________________________

Address of Program__________________________________________________________________________________________

Contact Person_____________________________________________ Phone_ __________________________________________

Terms of the Obligation_ ______________________________________________________________________________________

Are you in Default of the Obligation?

Date of Completion___________________________________________________________________________________________

Yes

No

12. Date you will be available to begin practice under the IHSLRP______________________________________________________

23

Indian Health Service Loan Repayment Program

Application Handbook
FORM APPROVED
OMB Approval No. 0917-0014
Exp. Date XX/XX/XX11

Section 2: Educational and Professional Background
(Educational and Professional Background for Graduates Only)
1. Name of Professional School___________________________________________________________________________________
School Address________________________________________________________________________________________________

Number

Street

Apt. or Room #

Graduate year and degree obtained_______________________________________________________________________________
2. Have you completed a residency or graduate program?
(MD, DO, DDS, PedNP, PA, etc.)

Yes

No_

2a. Year residency or program was/will be completed______________________________________________________________

Residency or Program Name___________________________________________________________________________________

Address___________________________________________________________________________________________________

Director of Residency/Program_ ________________________________________________________________________________

Name

Phone

2b. Specialty (for physicians only)________________________________________________________________________________

Board Certified

Board Eligible

Year re-certified (if applicable)_____________________

Sub-specialty (if applicable)_______________________

3. If applicable, please list all professional training location(s) separately.
a. Program Name______________________________________________________________________________________________
Address_ ____________________________________________________________________________________________________
Program Director’s Name_______________________________________________ Phone____________________________________
b. Program Name______________________________________________________________________________________________
Address_ ____________________________________________________________________________________________________
Program Director’s Name_______________________________________________ Phone____________________________________
c. Program Nme_______________________________________________________________________________________________
Address_ ____________________________________________________________________________________________________
Program Director’s Name_______________________________________________ Phone____________________________________
4. If applicable, describe your practice experience over the last 5 years._
(Include location, nature of population served, number of specialties in the practice, hospital affiliations and allocation of clinical
practice time to FP/GP, INT, OB/GYN, PED, PSYCH, ER. If you need more space, please use continuation sheet, type your name and SSN
at the top of each page, and attach to your application.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
24

Apply Here for Financial Freedom

Section 2 (continued)
5. For the last site at which you worked:
Name of Site Director or Official___________________________________________________________________________________
Your Job Title _________________________________________________________________________________________________
Address_ ____________________________________________________________________________________________________
Phone_______________________________________________________________________________________________________
6. Practice Time Allocation: Office-based_________ Hospital/clinic-based__________ Administration_ ________ Teaching________
7. Professional References (confidential)
Name

Position or Title

Address

Phone Number

8. Certification by Applicant
I certify that the information given in this application is accurate to the best of my knowledge and belief. I understand that it may be
investigated and that any willfully false representation is sufficient cause for rejection of this application, or if awarded a loan repayment,
that I am liable for repayment of all awarded funds and, further, that any false statement herein may be punished as a felony under
US Code, Title 18 Section 1001.

_____________________________________________________________________________________________________________

Signature (sign your full name in ink)
Date
SSN_ ______________________________________

25

Indian Health Service Loan Repayment Program

Application Handbook
FORM APPROVED
OMB Approval No. 0917-0014
Exp. Date XX/XX/XX11

Section 3: Financial Information
Important: As an applicant, you are applying for loan repayment with the Department of Health and Human Services (DHHS), Indian
Health Service Loan Repayment Program (IHSLRP) provided for in Public Law 100-713. It is important to submit your financial information
promptly to the IHSLRP.
Please complete the following information for each educational loan you submit to the IHSLRP. Include loan and payment documentation
with your application.
1. Name of lending institution and/or federal or state program________________________________________________________
Address_ ____________________________________________________________________________________________________
2. Date of Loan (mm/dd/yyyy)_ ________________________________________
3. Original Amount of Loan $________________________________________
4. Current Balance $_ ________________ Date of Balance_ _______________
5. Payment Amount $______________________________________________
6. Is loan in deferment?

Yes

No

IF YES, date deferment ends_ _______________________________________
7. Annual percentage rate (APR) of loan_______%
For consolidation of undergraduate and graduate educational loans
If you have consolidated your loans for undergraduate and graduate costs, you must attach a copy of the loan documents for health
professions education costs that were consolidated into a new loan. The IHSLRP pays for education costs for only one health professions
degree, and a determination will be made of the proportion of the consolidated loan that will be paid for successful applicants.
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 statute, 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.
8. Certification by Applicant
I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Secretary of DHHS for repayment
of the educational loans I have listed in Section 3.
I attest that my health educational loans were incurred solely for the purpose of paying for the costs of my education and reasonable living
expenses while attending college/university, and for obtaining a degree in medicine, dentistry, nursing, optometry, pharmacy, podiatry,
mental health or allied health profession.

_____________________________________________________________________________________________________________

Signature (sign your full name in ink)

Date

9. Lender Verification
I understand to the best of my knowledge that the loan identified above is a legally enforceable commercial, state or government
educational loan and its purpose was to pay for the borrower’s cost of completing a degree in medicine, dentistry, nursing, optometry,
pharmacy, podiatry, mental health or allied health profession.

_____________________________________________________________________________________________________________

26

Signature

Title

Date

Apply Here for Financial Freedom
FORM APPROVED
OMB Approval No. 0917-0014
Exp. Date XX/XX/XX11

Section 4: Comparison of Benefits Between Commissioned
Corps and Civil Service (Including Affidavit)
We ask that you read the following information on the two personnel systems used by the IHS: The Commissioned Corps and the Civil
Service. IHS is required to provide you with this information, in accordance with Public Law 100-713, Section 108(c)(1), to assist you in
making an informed decision as you consider employment with the IHS. After you have reviewed the personnel systems information,
please sign, date and return the affidavit to the IHS Loan Repayment Program as part of your completed application.

BENEFITS
A. Moving Expenses

B. Vacation Allowances

COMMISSIONED CORPS

CIVIL SERVICE

Call to active duty:

Call to active duty:

Pays to move officer’s family and household goods,
within certain weight limits, from current residence
to duty station.

Pays to move physician’s family and
household goods, within certain weight limits,
from current residence to duty station. Other
professions must consult human resources
office in the IHS area where you are hired.

On duty:

On duty:

Pays to move officer’s family and household goods,
within certain weight limits, from duty station to
duty station.

Pays to move an employee’s family and
household goods, within certain weight limits,
from duty station to duty station.

On separation or retirement:

On separation or retirement:

Pays to move officer’s family and household goods,
within certain weight limits, from duty station to
home of record or the place from which called to
duty, whichever is farther, or equivalent distance.

Provides no assistance in moving from final
duty station to next place of residence.

An officer earns 30 days of annual leave per year
(2-1⁄2 days per month) from the time he/she
enters on duty. A total of 60 days may be carried
from year to year and may be reimbursed on the
officer’s separation or retirement.

A civil servant earns 13 working days of annual
leave per year (4 hours per pay period, 26 pay
periods per year for the first 3 years). From the
fourth year through the 15th, he/she earns
6 hours of annual leave per pay period (20
working days per year). From the beginning
of the 16th year until retirement, 8 hours
of annual leave accrues per pay period, (26
working days per year). A total of 30 days
(240 hours) of annual leave may be carried
over from year to year and will be reimbursed
on separation or retirement.

27

Indian Health Service Loan Repayment Program

Application Handbook

Section 4 (continued)
BENEFITS

COMMISSIONED CORPS

CIVIL SERVICE

C. Sick Leave

No formal rate of accrual. Sick leave may be
granted when the officer is in need of medical
services or is incapacitated for the performance
of duties by sickness, injury, or pregnancy and
confinement. The leave granting authority or other
responsible official may require a medical certificate
for every period of sick leave in excess of 3 days, or
for a lesser period when determined necessary.

Sick leave is accrued at the rate of 4 hours
per pay period for the length of employment.
There is no maximum carry over limit.

D. Retirement

The Commissioned Corps retirement system is
structured on the basis of a 30-year career. Pay
increases based on length of service continue
throughout an officer’s career. Maximum retired
pay is based on 30 years of service (75 percent
of basic pay). With approval, an officer may retire
after completing 20, but less than 30, years of
active service. To be eligible for consideration for
such retirement, the officer must have 20 years
of creditable service. The Commissioned Corps
retirement system is noncontributory.

The Civil Service retirement system is a threetiered contributory comprehensive program
allowing Civil Service employees to control a
large portion of their retirement savings. The
program consists of a base retirement annuity,
social security benefits, and a government
matching savings program which allows
employees to invest the savings money
in government securities, the bond market
and/or the common stock market.

E. Health Insurance

Officer: US Public Health Service (PHS) officers are
entitled to health care from any Uniformed Service
Medical Treatment Facility (MTF). Health care
services may be supplemented by other resources
in accordance with Uniformed Service policies
and procedures.

Choice of medical and dental plans from
traditional fee-for-service plans to prepaid
HMOs. Employee payments and benefits vary
with the plan chosen. Benefits are provided
to employees and dependents on a cost
sharing basis.

Dependents: Dependents are entitled to health
care from a MTF on a space-available basis. TRICARE
is the name for the Department of Defense triple
option health care program. Dependents’ dental
care can be provided by voluntary enrollment in the
Active Duty Family Member Dental Plan.

28

Apply Here for Financial Freedom

Section 4 (continued)
BENEFITS

COMMISSIONED CORPS

CIVIL SERVICE

F. Tax Benefits

The basic allowance for quarters, variable
housing allowance, and subsistence
allowance are nontaxable. All other
pay is taxable.

All pay is taxable.

G. Military Benefits

Two years of active duty in the
Commissioned Corps satisfies a person’s
Selective Service obligation.

Civil Service makes no provision here.

H. Air Transportation

Officers are eligible to fly on military aircraft
within the US and overseas (foreign travel)
on a “space available” basis. Their families
may fly overseas only, on the same basis.

Civil Service makes no provision here.

I. Personal Amenities

Officers and dependents may use the
commissary, post exchange, transient officer
quarters and other facilities at military bases.

Civil Service makes no provision here.

J. Medical License

Must have a full and unrestricted license
in a state.

Must have a full and unrestricted license
in a state.

K. Impact of Loan Repayment
Program on Salary

Participation in the LRP has no impact
on pay.

Participation in the LRP will reduce or
eliminate the Physicians Comparability
Allowance. Physicians should discuss
this with their area recruiters.*

* If you are currently receiving a Physician’s Comparability Allowance (PCA) bonus, your participation in the IHSLRP may reduce or eliminate your eligibility to receive the PCA bonus.
The PCA bonus is only available to Civil Service employees. For further information, please contact the IHSLRP.

I certify that I have read the information regarding the Civil Service and Commissioned Corps Personnel Systems and understand that
I must select one to be employed by the Indian Health Service.

_____________________________________________________________________________________________________________

Name (please print)

Signature

Date

29

Indian Health Service Loan Repayment Program

Application Handbook
FORM APPROVED
OMB Approval No. 0917-0014
Exp. Date XX/XX/XX11

Section 5: Sample LRP Contract

5. T o defer performance of a participant’s period of obligated
service if the participant:

This section is a sample Loan Repayment Program Contract. You
will receive an official copy to sign and return if you are selected
for an award. When you sign the contract, you will be agreeing to
a service obligation to provide full-time clinical service in an Indian
health program for one year for each year of loan repayment.
Please read this sample contract thoroughly so that you fully
understand all provisions. If you have any questions regarding
the contract, call the LRP office at (301) 443-3396.

a. R
 eceives a degree from a school of medicine, osteopathy,
dentistry, optometry, podiatry, pharmacy, nursing,
psychology, public health, social work, or other health
profession, and

b. R
 equests a deferment of this period to complete
internship, residency, or other advanced clinical training.
The period of deferment may not exceed:

(1) three

years for participants receiving a degree from
schools of medicine, osteopathy or dentistry, or

(2) o
 ne year for participants receiving a degree from
schools of optometry, podiatry, pharmacy, nursing,
psychology, public health, social work, or other health
professions. The Secretary may, however, extend this
period of deferment if the Secretary determines that
the extension is consistent with the needs of the IHS.

Loan Repayment Program — Sample Contract
Section 108 of the Indian Health Care Improvement Act (Public
L. 94-437), as amended, authorizes the Secretary of Health
and Human Services (Secretary), acting through the Indian
Health Service (IHS), to establish the Indian Health Service Loan
Repayment Program (IHSLRP) under which Federal, State, and
commercial loans for physicians and other health professionals may
be repaid at a rate not to exceed $20,000 per year. In return for
such loan repayment, participants must agree to provide full-time
clinical service in an Indian health program for a period of obligated
service equal to one year for each year of loan repayment. Section
108 requires participants to submit with their applications a written
contract to accept repayment of educational loans and to serve
for the applicable period of obligated service in an Indian health
program. The Secretary shall sign only those contracts submitted
by participants who are selected for the program.

Section B — Obligation of the Participant
If selected, the participant agrees:
1. T o accept loan repayment provided by the Secretary under
Section A of this contract and to apply such payments only to
outstanding eligible health professions educational loans.
2. To serve in accordance with this Section for 2 years;
*3. Participant’s health profession____________________________

Section A — Obligations of the Secretary
Subject to the availability of funds appropriated by Congress
for the IHS and the IHSLRP, the Secretary agrees to:
1. M
 ake payments to the participant for each year of service
of the lesser of up to $20,000 or the total amount of the
participant’s eligible health professions educational loans
divided by the number of years of obligated service.
Loans eligible for repayment consist of loan costs identified
by the promissory note indicating the principal, interest, and
related expenses on Federal, State, and commercial loans
received by the participant for tuition expenses; all other
reasonable educational expenses, incurred by the participant;
and reasonable living expenses as determined by the Secretary.
2. T o accept the participant into the IHS or place the participant
with a tribe, tribal or Indian organization provided that the
participant meets all appropriate employment qualifications.
3. T o make loan repayments for each year of obligated service
no later than the end of the fiscal year (September 30, ____)
in which the participant completes such year of obligated
service. All contracts are for whole years [for example: 2
whole years and no fraction or part of a year(s)].
4. P
 ay, on behalf of the participant an amount not less than 20
percent and not more than 39 percent of the participant’s total
amount of loan repayments, to the Internal Revenue Service
for all or part of the increased tax liability.
30

* Must be completed by participant.
4. In the case of a participant described in Section 108(b)
(1)(A)(B)(i)(ii), (i.e., In the final year of a course of study
or in an approved graduate training program):

a. T o maintain enrollment in a course of study or training, to
maintain an acceptable level of academic standing.

5. T o serve for a time period (hereinafter referred to as the “period
of obligated service”) equal to 2 years or such longer period
as the participant may agree to serve in the full-time clinical
practice of the participant’s profession in an Indian health
program to which the participant may be assigned by the
Secretary.
6. T o accept assignment, as determined by the Secretary, for
the participant’s full period of obligated service in a Loan
Repayment priority site designated for the participant’s
profession or specialty by the IHS.
7. T o have a current and unrestricted license or certificate, as
necessary for the participant’s profession, to practice the
participant’s health profession in a State within the United
States prior to commencing obligated service and maintain
that license or certificate throughout the period of obligated
service.
8. T o commence obligated service in accordance with this
contract prior to September 30,____ , and continue
uninterrupted service for the duration of the participant’s

Apply Here for Financial Freedom

service obligation period except as provided in Section G
of this contract or unless participant’s service obligation
is deferred by the Secretary pursuant to Section A(5) of
this contract.
9. T o comply with the provisions of Title 42, Code of Federal
Register, Part 36, Subpart J, when adopted. Should any
provision of Subpart J be inconsistent with this contract,
the regulatory provision will be controlling.
10. P
 articipants serving a contract extension under Section E —
Contract Extension have served at least a 2-year time “period
of obligated service” prescribed in Section 108(f)(1)(B)(iii) of
the Indian Health Care Improvement Act (Public Law 94-437)
as amended by the Indian Health Care Amendments of 1992
(Public Law 102-573).
11. A
 ll IHS Loan Repayment Program (IHSLRP) Participants must
forward in writing any change of address, financial institution,
or employment status within 30 days to the following
address:

Indian Health Service Loan Repayment Program
801 Thompson Avenue, Suite 120
Rockville, MD 20852

12. A
 ny Participant who is terminated or resigns from their place
of Employment must submit in writing the reason for their
non-employment within 30 days or will be placed into
Default and debt collection proceedings will be initiated.
Section C — Contract
The effective date of the contract is calculated from the date it
is signed by the Secretary or his/her delegate, or the IHS tribal,
tribal/urban, or “Buy-Indian” health center entry-on-duty date,
whichever is more recent. If already on duty with the IHS or
other Indian health program, calculate from the date of contract;
if contract is signed prior to reporting to duty, calculate from the
entry-on-duty date.
Section D — Payments
Payments will begin within 120 days from the date the contract
becomes effective (calculated from the date the contract is signed
by the Secretary or his/her delegate, or the IHS, tribal/urban
organization, or “Buy-Indian” health center entry-on-duty date,
whichever is more recent. If already on duty with the IHS or other
Indian health program, calculate from the date of contract; if
contract is signed prior to reporting to duty, calculate from the
entry-on-duty date). Contract extensions will be paid 120 days
from initial anniversary date. (See Section E.)

a. T he participant remains eligible for participation in the
IHSLRP, and

b. T he total period of obligated service does not exceed that
number of years that it will take to repay the total amount
of the individual’s outstanding eligible health professions
educational loans up to $20,000 per year under the terms
and conditions of this contract.
Individuals extending a contract initially approved prior
to FY 2000 are eligible to receive the total amount of the
individual’s outstanding health professions educational
loans up to $30,000 per year under the terms and
conditions of this contract.

3. P
 articipants will be allowed to submit additional Section III
financial information not covered under their initial verification
of debt, as long as the debt to be considered meets the
provisions in the subject section entitled,“For Consolidation of
Undergraduate and Graduate Educational Loans”, and complies
with subsection (2)(b) of this section.
Once the Secretary or his/her authorized representative
approves a contract extension, the period of obligated service
thereunder shall be calculated beginning the first day after
which the participant’s initial period of obligated service
is completed, if completed the same fiscal year in which
the contract extension is approved and if the participant
remains on duty after completion of his/her initial period
of obligated service. However, when program funds are
exhausted, the Secretary will not sign and approve contract
extension requests and no credit will be given for the time
served after the completion of the initial obligated service.
Loan Repayment participants are therefore encouraged to
make their contract extension requests as early as possible,
preferably 9 months prior to the completion of their initial
period of obligated service.
**4. T o serve in accordance with Section E — Contract Extension
for a period of 1 year.
(This provision applies only to those LRP participants who
have completed their 2-year period of obligated service.
5. A
 ll requests for a Contract Extension must include a payment
history from your lending institution(s) indicating that
maximum payments from the IHSLRP were applied to
your eligible outstanding debt since your acceptance into
the IHSLRP.
** Must be initialed by participant if applying for
a Contract Extension.)

Section E — Contract Extension
1. Participants may, in accordance with procedures established by
the Secretary, request an extension of this contract.
2. S ubject to the availability of funds appropriated by the Congress
of the United States for the IHS and the IHSLRP, the Secretary
may approve requests for extension of this contract if:
31

Indian Health Service Loan Repayment Program

Application Handbook

Section F — Breach of Loan Repayment Contract, Damages
1. If a participant who has entered into a written contract with
the Secretary and who —

a. Is enrolled in the final year of a course of study and who —

(1) fails

to maintain an acceptable level of academic
standing in the educational institution in which the
participant is enrolled;

(2) voluntarily terminates such enrollment; or

(3) is
 dismissed from such educational institution before
completion of such course of study; or

(4) fails

to apply loan repayments to his/her health
professions educational loans; or

2. If, for any reason not specified in paragraph (1), an applicant
breaches his/her written contract by failing either to begin,
or complete, the participant’s period of obligated service in
accordance with Section 108(f), the United States shall be
entitled to recover from the participant an amount to be
determined in accordance with the following formula:
A = 3Z[(t-s)/t] in which:

a. “A” is the amount the United States is entitled to recover;

b. “ Z” is the sum of the amounts paid under this Section
to, or on behalf of, the participant and the interest on
such amounts which would be payable if, at the time the
amounts were paid, they were loans bearing interest at
the maximum legal prevailing rate, as determined by the
Treasurer of the United States;

c. “t” is the total number of months in the participant’s
period of obligated service in accordance with Section
108(f); and

d. “ s” is the number of months of such period served by
such participant in accordance with this section.

3. A
 ny amount of damages which the United States is entitled
to receive under this contract shall be subject to the United
States within the one-year period beginning on the date of
the breach or such longer period beginning on such date
as shall be specified by the Secretary, and may include all
collection costs including any litigation costs. Amounts not
paid within the one-year period shall be subject to collection
through deductions in Medicare payments pursuant to Section
1892 of the Social Security Act.
4. U
 nsatisfactory performance by the applicant resulting in
the termination of the participant’s employment during the
participant’s period of obligated service shall be considered
a breach of this contract.

32

Section G — Creditability of Graduate Training Toward
Period of Obligated Service
1. N
 o credit of time for internship, residency, or other advanced
clinical training will be counted toward satisfying the period
of obligated service incurred under this contract.
Section H — Cancellation, Suspension, Waiver,
and Release of Obligation
1. A
 ny service or payment obligation incurred by the participant
under this contract will be cancelled upon the participant’s death.
2. T he Secretary may waive or suspend, in whole or in part, the
participant’s service obligation incurred under this contract if
compliance by the applicant is impossible or would involve
extreme hardship to the individual and if enforcement of
such obligation with respect to the participant would
be unconscionable.
3. T he Secretary may waive, in whole or in part, the rights of the
United States to recover amounts under this Section in any
case of extreme hardship, as determined by the Secretary.
4. A
 ny obligation of a participant under the Loan Repayment
Program for payment of damages may be released by a
discharge in bankruptcy under Title 11 of the United States
Code only if such discharge is granted after the expiration of
the 5-year period beginning on the date that payment of such
damages is required and only if the bankruptcy court finds that
non-discharge of the obligation would be unconscionable.
5. A
 ll Waiver requests to the IHSLRP must be made in writing.
Any IHSLRP Waiver approval, denial, or decision will be made
to the Applicant in writing within 30 days of the Waiver
Committee’s decision.

Apply Here for Financial Freedom

Section I—Drug Free Workplace Certification
By signing and submitting this contract, the Indian Health Service Loan Repayment participant certifies, in accordance with 45 CFR Part
76, as a condition of the contract, he/she will not engage in the unlawful manufacture, distribution, dispensing, possession, or use of a
controlled substance while conducting any activity under the contract..

_____________________________________________________________________________________________________________
Participant’s Name (Please Print or Type)

Participant’s Signature

Date

I understand that any financial obligation of the United States arising out of this contract and my obligation arising out of this
contract is contingent upon funds being appropriated by Congress for the IHS Loan Repayment Program. The Secretary or his/her
authorized representative must sign this contract before it becomes effective. Further, I understand that any indebtedness I incur
prior to both parties, the Secretary and myself, signing this contract is my responsibility.

_____________________________________________________________________________________________________________
Participant’s Name (Please Print or Type)

Participant’s Signature

Date

_____________________________________________________________________________________________________________
Secretary of Health and Human Service (or delegate’s) Signature

Date

For Official Use Only
Participant’s account will be obligated for $________________ and will serve his/her ________ year obligation at the following site.
_________________________________________________________________________________________________________________________________
Official ______________________________________________________

Date__________________________________________________________

Appropriation Number: _________________________________________

CAN__________________________________________________________

33