Form 10-XXX Specialty Education Loan Repayment Program (SELRP) - Edu

SPECIALITY EDUCATION LOAN REPAYMENT
PROGRAM - EDUCATION LOAN VERIFICATION FORM
The VA is asking you to provide the information on this form in order for VA to determine your eligibility to receive an education debt reduction payment award.
VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law
enforcement congressional communications the collection of money owed to the United States, litigation in which the United States is a party or has an interest; the
administration of VA training, scholarship and education debt reduction programs, including verification of your eligibility to participate; and personnel
administration. You do not have to provide this information to VA, but if you do not, VA will be unable to process your request for consideration in this program. If
you give VA your social security number, VA will use it to obtain information relevant to determining whether to grant an loan repayment program award, and to
administer your education loan repayment, if awarded. It also may be used for other purposes authorized or required by law.
SECTION A – TO BE COMPLETED BY APPLICANT
As an applicant, you are applying for an educational assistance award that is offered in accordance with SELRP regulations.
1. LAST, FIRST, MI

2. SSN
SECTION B – TO BE COMPLETED BY THE LENDING INSTITUTION

3. NAME OF LENDING INSTITUTION
4. PHYSICAL ADDRESS OF LENDING INSTITUTION
LOAN 1 ACCOUNT NUMBER:
IS THIS A CONSOLIDATED LOAN?
DATE OF LOAN

NO
YES
ORIGINAL AMOUNT

If yes, see note at end of form.
MONTHLY PAYMENT

IS LOAN IN DEFERMENT/FORBEARANCE?
YES
NO

CURRENT BALANCE

ANNUAL % RATE

HAS THIS LOAN BEEN REFERRED TO A COLLECTION
AGENCY OR PLACED IN DEFAULT STATUS?

If yes, include date deferment ends:

YES

NO

LOAN 2 ACCOUNT NUMBER:
IS THIS A CONSOLIDATED LOAN?
NO
YES
DATE OF LOAN
ORIGINAL AMOUNT

If yes, see note at end of form.
MONTHLY PAYMENT

IS LOAN IN DEFERMENT/FORBEARANCE?
YES
NO

DATE OF LOAN

NO
YES
ORIGINAL AMOUNT

ANNUAL % RATE

HAS THIS LOAN BEEN REFERRED TO A COLLECTION
AGENCY OR PLACED IN DEFAULT STATUS?

If yes, include date deferment ends:
LOAN 3 ACCOUNT NUMBER:
IS THIS A CONSOLIDATED LOAN?

CURRENT BALANCE

YES

NO

If yes, see note at end of form.
MONTHLY PAYMENT

IS LOAN IN DEFERMENT/FORBEARANCE?
YES
NO

If yes, include date deferment ends:

CURRENT BALANCE

ANNUAL % RATE

HAS THIS LOAN BEEN REFERRED TO A COLLECTION
AGENCY OR PLACED IN DEFAULT STATUS?
YES

NO

PROVIDE THE FOLLOWING IF LOAN(S) TRANSFERRED OR SOLD FROM ANOTHER LENDER OR SERVICER:
NAME OF LENDER/SERVICER
DATE OF TRANSFER
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 statue, 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. I understand that to the best of my knowledge that the loan(s) identified
above are legally enforceable commercial, government or state educational loans and its purpose was to pay for the borrower’s cost to complete an educational
degree.
SIGNATURE OF AUTHORIZED LENDING REPRESENTATIVE:

DATE:

I hereby certify to the accuracy of the above information and I apply to enter into an agreement with the Under Secretary for Health for an education loan repayment
award to reduce the amount of principle and interest owed on the education loan listed on this form. I attest that my health educational loan was incurred solely for
the purpose of paying for the costs of my education, and reasonable living expenses while attending school to obtain a degree for the position for which I am
applying and/or appointed.
SIGNATURE OF APPLICANT:

VA FORM
JAN 2020

10-XXX

DATE:

PAGE 1 OF 1