0917-0014 Financial Information

IHS Loan Repayment Application - Financial Information

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Indian Health Careers

Form Approved, OMB Approval No. 0917-0014, Expiration Date: 07/31/15

Financial Information

LRP Basics

Important: As an applicant, you are applying for loan repayment with the Department of Health and Human Services (HHS), Indian Health Service
(IHS) Loan Repayment Program (LRP) provided for in P.L. 100-713. It is important to submit your financial information promptly to the LRP. Please

Policies
and Procedures 

complete the following information for each educational loan you submit to the LRP.

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You may fax or mail loan and payment documentation.
*indicates required field

FAQs

You indicated you have 1 loans

Contact the LRP Office

Loan 1
* Name of lending institution and/or federal or state program
Address

Date of Loan

* Original Amount of Loan $
Payment Amount $

   * Current Balance $
No
  Is Loan in Deferment? No

Annual percentage rate (APR) of loan

(mm/dd/yyyy)   

* Date of Balance
    If YES, date deferment ends

(mm/dd/yyyy)
(mm/dd/yyyy)

%

For consolidation of undergraduate and graduate educational loans
If you have consolidated your loans for undergraduate and graduate costs, you must attach copies of the loan documents for health professions
education costs that were consolidated into a new loan. The LRP 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.
Certification by Applicant
I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Secretary of HHS 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.
Lender Verification - You will be required to submit to us lender documentation verifying each loan
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.
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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

https://www.ihs.gov/loanrepayment/lrpOnlineApp/index.cfm?module=loans[4/2/2015 3:39:19 PM]

IHS Loan Repayment Application - Financial Information
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.

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https://www.ihs.gov/loanrepayment/lrpOnlineApp/index.cfm?module=loans[4/2/2015 3:39:19 PM]