Form 10-255b Specialty Education Loan Repayment Program (SELRP) - Pro

OMB Control No: 2900-0879
Estimated Burden: 10 min
Expiration Date: XXX XX, 2023

SPECIALTY EDUCATION LOAN REPAYMENT
PROGRAM - PROGRAM STATUS VERIFICATION
The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Therefore, we may not conduct or
sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete
this form will average 10 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and fill out the form. Participation in this program is voluntary, but
failure to provide complete and accurate responses on the application may impact your selection to participate in and receive the benefits of the program.
Privacy Act Notice: The VA is asking you to provide the information on this form under the authority of 38 U.S.C. 7502 and 7602 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 interest; the
administration of VA training, scholarship and education 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 may 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 a 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.

PART I - EMPLOYEE CERTIFICATION AND AUTHORIZATION FOR RELEASE OF INFORMATION
CONSENT: I authorize the educational institution in which I am, or will be, enrolled to release to VA information regarding my medical
residency program status and standing. I understand that this authorization is voluntary, and that I may revoke this consent at any time. However,
I further understand that if I voluntarily revoke this authorization after the award of SELRP funds, my participation in the SELRP program and
placement with the VA may be terminated and I may be liable for damages in accordance with provisions under the SELRP.
PARTICIPANT NAME:
PARTICIPANT SIGNATURE:

DATE:

PART II – PROGRAM DIRECTOR VERIFICATION
I verify the individual is in good standing and recommended for continued participation in the VA SELRP.
PROGRAM DIRECTOR NAME:
PROGRAM DIRECTOR SIGNATURE:

DATE:

PROJECTED MONTH AND YEAR OF RESIDENT’S PROGRAM COMPLETION:

VA FORM
NOV 2020

10-255b

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