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

SPECIALTY EDUCATION LOAN REPAYMENT
PROGRAM PARTICIPANT AGREEMENT

APPLICANT INFORMATION
NAME:

CLINICAL SPECIALTY:

VA OFFICE USE ONLY
RECEIVED:

CERTIFIED COMPLETE:

CONDITIONS
SECTION A - Obligations of the Under Secretary for Health (USH)
Subject to availability of funds appropriated by the Congress of the United States the USH agrees to:
1. Provide the undersigned individual with the SELRP award specified in the Section E, contingent upon the individual's eligibility and program
qualifications.
2. Ensure that each individual selected to participate in the SERLP is eligible at the time an award is conferred.
3. Appoint the participant to a permanent, full-time positions providing health care services at a VA facility provided the individual completes all
necessary prerequisites
4. This employment will begin within 90 days after the participant completes the HPSP-supported education or training and meets all the applicable
qualification and licensure requirements for appointment to the position. This time period may be extended at the USH's discretion. At least 60
days prior to the appointment date, the participant will be notified of location and beginning date of obligated service.
SECTION B - Obligations of the Participant
In consideration of payment under the SELRP, the participant agrees to:
1. Accept the SELRP award and associate periods of obligated service at the VA facility provided by the VA under Section E of this form.
2. Maintain an acceptable level of performance and conduct in the position for which the award was authorized for the periods of service specified in
Section E.
3. Notify the Program Coordinator in writing of any of the following changes within 10 working days: name, address, telephone number, email, and/or
employment status.
4. Immediately notify the Program Coordinator when the eligible education loan balance(s) is completely liquidated, understanding that no additional
loan payments can be made exceeding the total outstanding loan balance, including interest.
5. Ensure that VA Program Officials have access to loan documents and related information to assess the authenticity of the education debt, the
amount of outstanding principal and interest and records of payments pf principal and interest on the qualifying loan(s).
6. Submit required documentation periodically to VA Program Officials as requested in order to continue program participation.
SECTION C - Early Termination of SELRP Participation
1. A participant who is separated due to a staffing adjustment or a reduction in force before completing a service period under the SELRP
Acceptance of Conditions shall not be required to repay VA. No payments will be authorized for subsequent periods covered under the
Acceptance of Conditions.
2. Breach Agreement:
a. A participant who receives or is subject to sustained formal disciplinary/adverse action or who receives a performance rating of less than fully
successful or proficiency rating of less than satisfactory during an SELRP service period will be terminated from the program. The participant is
not eligible to receive an education debt reduction payment for the service period in which the discipline/action or rating occurred, will be
required to reimburse VA any funding received during that period and subsequent service periods.
b. A participant who makes no loan payments during a service period will be terminated from SELRP and will become indebted to VA for the
amount paid or payable to the participant.
c. A participant who elects to leave the position for which he or she was appointed to under SELRP will become indebted to VA for the amount
paid or payable to the participant, reduced by the proportion of days served for the completion of the period of all total obligated service periods.
Exceptions will be considered only if change in positions is determined to be in the interest of the VA, subject to approval by the VA's delegated
authority.
d. The repayment period for any damages that the United States is entitled to recover under this section will be paid no later than I year after the
breach of the agreement.

VA FORM
JAN 2020

10-XXX

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CONDITIONS (Continued)
SECTION E - Award Amount
The participant is awarded SELRP payments for full-time/part-time duty in the amounts specified for the service period below:
VA FACILITY AND STATION CODE:
SERVICE PERIOD
SERVICE PERIOD 1
SERVICE PERIOD 2*
SERVICE PERIOD 3
SERVICE PERIOD 4
SERVICE PERIOD 5

DATE BEGINS

DATE ENDS

AMOUNT

*A minimum of two service periods is required.
The participant will receive a SELRP payment within the first fiscal year quarter of their applicable service period. Participants must provide proof
of loan payment to their servicers quarterly. The first service period begins on the day after an SELRP acceptance of conditions is consummated.
The amounts specified are the maximum award amounts that an employee may receive during a service period. In no case will a participant be
entitled to receive debt reduction payment that exceeds the amount that they actually paid to reduce the principal and interest on the qualifying
loan(s) during a service period.
• The maximum award amount that a part-time participant may receive is prorated by the proportion of the participant's part-time hours to the hours
of a full-time employee.
• Every eight hours of non-pay status will extend the service period by one calendar day.
SECTION F - General Provisions
The VA authorize representative must sign the Acceptance of Conditions form to consummate a SELRP award. The award becomes effective the
day after the form is consummated. As an applicant for a debt reduction award, I agree to comply with the regulations issued by VA to implement the
SELRP.
NAME OF AWARDEE:

SIGNATURE OF AUTHORIZED REPRESENTATIVE:

VA FORM 10-XXX, JAN 2020

SIGNATURE OF AWARDEE:

DATE:

DATE:

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