IHS Loan Application

Indian Health Service Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0014 can be found here:

Documents and Forms

Document Name Document Type
Form 0917-0014 IHS Loan Application Form
0917-0014 Financial information financial.pdf www.ihs.gov/loanrepayment/lrpOnlineApp/ Form
0917-0014 Education Information education.pdf www.ihs.gov/loanrepayment/lrpOnlineApp/ Form
0917-0014 General Applicant Information general_applicant_info.pdf www.ihs.gov/loanrepayment/lrpOnlineApp/ Form

Information Collection (IC) Details

IC Title:	IHS Loan Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 1320.5(d)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0917-0014	Financial information	financial.pdf	https://www.ihs.gov/loanrepayment/lrpOnlineApp/	Yes	Yes	Fillable Fileable
Form	0917-0014	Education Information	education.pdf	https://www.ihs.gov/loanrepayment/lrpOnlineApp/	Yes	Yes	Fillable Fileable
Form	0917-0014	General Applicant Information	general_applicant_info.pdf	https://www.ihs.gov/loanrepayment/lrpOnlineApp/	No	No	Fillable Fileable

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 510	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	510	0	510
Annual IC Time Burden (Hours)	765	612	153
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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