OMB
No. 1845-0104 Form
Approved Exp.
Date 11/30/2010 CLAA |
2010 CIVIL LEGAL ASSISTANCE ATTORNEY STUDENT LOAN REPAYMENT PROGRAM ANNUAL CERTIFICATION OF EMPLOYMENT Federal Perkins
Loan Program / Federal Family Education Loan Program /
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Before completing this form, carefully read the entire form, including the information on pages 2 - 4. Type or print using dark ink. Show dates as MM-DD-YYYY (for example, show “January 1, 2010” as “01-01-2010”). Keep a copy of this form and any documentation that you send with this form for your records. Return the completed form to the address shown in Section 8. |
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SECTION 1: BORROWER’S IDENTIFICATION |
Please print the following information. |
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Last Name |
First Name |
Middle Initial |
Social Security Number |
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Street Address |
Area Code/Telephone Number (home) |
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City |
State |
Zip Code |
Area Code/Telephone Number (other) |
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E-Mail Address (optional) |
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SECTION 2: BORROWER’S CERTIFICATION OF ELIGIBILITY FOR PAYMENT OF ELIGIBLE LOAN(S) |
The borrower must sign this section. |
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I request that the U.S. Department of Education (the Department) repay my eligible Federal Perkins Loan (Perkins Loan), Federal Family Education Loan (FFEL) and/or William D. Ford Federal Direct Loan (Direct Loan) program loans, up to the maximum amount for which I am eligible under the Civil Legal Assistance Attorney Student Loan Repayment program. I acknowledge that I have previously signed a Service Agreement with the Department under the terms reflected in Section 5. I certify that I:
I certify that I have not received benefits for the same service under both this program and the Loan Forgiveness for Service in Areas of National Need Program under section 428K of the Higher Education Act of 1965, as amended (HEA), 20 U.S.C. 1078-11 or the Public Service Loan Forgiveness Program under section 455(m) of the HEA, 20 U.S.C. 1087e (m). The information that I have provided on this form is true and correct. |
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Borrower’s Signature
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Date |
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SECTION 3: EMPLOYER’S CERTIFICATION |
An authorized certifying official of the borrower’s employer must complete this section. |
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Before completing this section, carefully read the entire form, including the General Information in Section 4, the Terms Conditions and other information in Section 5, and the Definitions in Section 6. Type or print using dark ink. Show dates as MM-DD-YYYY (for example, show “January 1, 2010” as “01-01-2010”). |
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I certify that the borrower named above was employed full-time, from |__|__|-|__|__|-|__|__|__|__| to |__|__|-|__|__|-|__|__|__|__| as a civil legal assistance attorney, as defined in Section 6, by the nonprofit organization, protection and advocacy system, or client assistance program identified below. |
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Name of Employer |
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Employer’s Address (Street, City, State, Zip) |
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Name/Title of Authorized Certifying Official (Printed) |
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Area Code/Telephone Number |
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Signature of Authorized Certifying Official |
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Date |
SECTION 4: GENERAL INFORMATION FOR THE CIVIL LEGAL ASSISTANCE ATTORNEY STUDENT LOAN REPAYMENT PROGRAM |
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SECTION 5: TERMS AND CONDITIONS OF THE SERVICE AGREEMENT BETWEEN THE BORROWER AND THE DEPARTMENT OF EDUCATION, AND APPLICATION OF APPROVED REPAYMENT AMOUNTS |
To be eligible to receive and retain payment benefits under the Civil Legal Assistance Attorney Student Loan Repayment Program, I, previously agreed to the following terms of service:
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SECTION 6: DEFINITIONS |
(A) A nonprofit organization that provides legal assistance with respect to civil matters to low-income individuals without a fee, or (B) A protection and advocacy system or client assistance program that provides legal assistance to clients with respect to civil matters and receives funding under- (1) Subtitle C of title I of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15041 et seq.); (2) Section 112 or section 509 of the Rehabilitation Act of 1973 (29 U.S.C. 732, 794e); (3) Part A of title I of the Protection and Advocacy for Individuals with Mental Illness Act (42 U.S.C. 10801 et seq.); (4) Section 5 of the Assistive Technology Act of 1998 (29 U.S.C. 3004); (5) Section 1150 of the Social Security Act (42 U.S.C. 1320b-21); (6) Section 1253 of the Public Health Service Act (42 U.S.C. 300d-53); or (7) Section 291 of the Help America Vote Act of 2002 (42 U.S.C. 15461). Section 6 (Definitions) continues on next page. |
SECTION 6: DEFINITIONS (continued) |
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The Perkins Loan Program includes Federal Perkins Loans. The Perkins Loan Program was previously named the National Direct Student Loan (NDSL) Program, which was a continuation of the National Defense Loan (Defense Loan) Program. The FFEL Program includes Federal Stafford Loans (both subsidized and unsubsidized), Federal PLUS Loans, Federal Consolidation Loans, and Federal Supplemental Loans for Students (SLS). The Direct Loan Program includes Federal Direct Stafford/Ford (Direct Subsidized) Loans, Federal Direct Unsubsidized Stafford/Ford (Direct Unsubsidized) Loans, Federal Direct PLUS (Direct PLUS) Loans, and Federal Direct Consolidation (Direct Consolidation) Loans.
(1) An annual average of at least 30 hours per week, or (2) Unless the qualifying employment is with two or more employers, the number of hours the employer considers full-time. (B) Vacation or leave time provided by the employer or leave taken for a condition that is a qualifying reason under the Family and Medical Leave Act of 1993, 29 U.S.C. 2612(a)(1) and (3) is not considered in determining the average hours worked on an annual basis.
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SECTION 7: IMPORTANT NOTICES |
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Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authorities for collecting the requested information from and about you are §421 et seq., §451 et seq., and/or §461 et seq. of the Higher Education Act of 1965, as amended (the HEA) (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., and/or 20 U.S.C. 1087aa et seq.), and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and §31001(i)(1) of the Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)). Participating in the Federal Family Education Loan (FFEL) Program, the William D. Ford Federal Direct Loan (Direct Loan) Program, and/or the Federal Perkins Loan (Perkins Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate. The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the FFEL Program, Direct Loan Program, and/or Perkins Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. We also use your SSN as an account identifier and to permit you to access your account information electronically. The information in your file may be disclosed, on a case-by-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions to efficiently submit student enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies. In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Paperwork Reduction Notice: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0104. The time required to complete this information collection is estimated to average 0.20 hours (12 minutes) for the borrower per response and 0.25 (15 minutes) for the employer, including the time to review instructions, search existing data resources, gather and maintain the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have any comments or concerns regarding the status of your individual submission of this form, write directly to the address shown below. |
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SECTION 8: WHERE TO SEND THE COMPLETED CERTIFICATION OF EMPLOYMENT |
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Return the completed Certification of Employment to: U.S. Department of Education Civil Legal Assistance Attorney Student Loan Repayment Program PO Box 4399 Utica, NY 13504
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If you need assistance with this form, call:
1-877-699-1834 |
Page
File Type | application/msword |
File Title | Draft Child Care Provider Loan Forgiveness App |
Subject | CCPLF |
Author | Don E. Watson |
Last Modified By | James Hyler |
File Modified | 2010-11-04 |
File Created | 2010-11-04 |