Form 10-255e Specialty Education Loan Repayment Program (SELRP) - Par

OMB Control No: 2900-0879
Estimated Burden: 15 min
Expiration Date: XXX XX, 2023

SPECIALTY EDUCATION LOAN REPAYMENT
PROGRAM PARTICIPANT AGREEMENT

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 15 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. 7693 in order for VA to determine your eligibility to receive a
Specialty Education Loan Repayment Program 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 Specialty Education 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.

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 Section B1, 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 position providing health care services at a VA facility provided the individual completes all
necessary prerequisites.
Note: This employment will begin within 90-days after the participant completes the training program for which SELRP has been awarded 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.
The participant is awarded SELRP payments for full-time duty in the amounts specified for the service period below:
SERVICE BEGINS
SERVICE ENDS
AWARD

*A minimum of two service periods is required. 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 participant will receive a SELRP
payment within the first quarter of the fiscal year of their applicable service period. Participants must provide proof of loan payment to their services
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.
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 B1.
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.
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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 1 year after the
breach of the agreement.

SECTION D - General Provisions

CONDITIONS (Continued)

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 AWARDEE:

SIGNATURE OF THE USH OR DESIGNATED REPRESENTATIVE:

VA FORM
NOV 2020

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DATE:

DATE:

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