Application Part 2 Application Part 2

NIFA Veterinary Medicine

Loan Repayment Program (VMLRP)

APPLICATION PART 2: FINANCIAL

National Institute of Food and Agriculture

US Department of Agriculture

OMB No. 0524-0050

Form Approved For Use Through XX/XX/XXXX

Purpose: This form is to be completed by the applicant to provide veterinary educational loan information.

Instructions: Complete Sections 1-3 for each loan servicer with which you have outstanding veterinary medical educational debt. All loans must be listed for each servicer. If you have loans with different servicers, complete a separate form for each servicer. If your loans have been consolidated into one loan account, only submit one form for the servicer of the consolidated loan.

Important: The completion of this form requires accurate and comprehensive information as of the time of submittal. We recommend you gather your educational loan information before starting to complete this form. Submit this form according to the instructions detailed in the Notice of Funding Opportunity (NOFO) (https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-request-applications-rfa). For additional information to prepare your loan documentation, visit the VMLRP Applicant’s website (https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-applicants).

Section 1. Loan Information

Applicant’s Name:

Name of Loan Servicer:

Loan Servicer Account

Number:

Address to where

payments are sent:

Section 2. Loan Details and Repayment Information

Original Total Amount of Loan(s):
Total Loan Balance as of Submittal Date:
Are you currently repaying the loan(s)?	Yes No	If no, are the loans in deferment or forbearance status?	Yes No
Are your payments up to date?	Yes No	Does this loan information include a consolidated loan?	Yes No

Is this loan consolidated with undergraduate loans?

Yes No

If this is a consolidated loan, were any loans past due or delinquent prior to consolidation?

Yes No Not Applicable

You are also required to include supporting loan documentation as identified within the NOFO with your submittal. Please refer to the Loan Document tutorial at the VMLRP Applicant’s website (https://www.nifa.usda.gov/grants/programs/veterinary-medicine-loan-repayment-program/vmlrp-applicants) for a detailed explanation on the required loan documents.

If you consolidated your veterinary school loans with other educational loans (e.g. undergraduate), you must include the details of your undergraduate student loans within your submittal as described within the NOFO. There is a section on the VMLRP website explaining how your loan consolidation may affect your eligibility and award level for the VMLRP.

Section 3. Certifications by Applicant/Borrower

Applicant/Borrower

I hereby apply to enter into an agreement with the U.S. Secretary of Agriculture for repayment of the educational loan listed above, incurred solely for the costs of education, including reasonable living expenses. I hereby certify the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact that would render the information false, fraudulent, or fictitious because of the omission. I am aware any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986. I hereby authorize the lending institution and/or servicing agent named above to release information about my loan, or any loan owned, serviced, or administered by my lending institution, servicing agent, or program administrator to the administrators of the NIFA VMLRP, and to other authorized Government officials. This authorization shall remain in effect from the date of submittal of my application and throughout my participation in the NIFA VMLRP, up to and including 120 days after completion of my VMLRP agreement service.

Certification of Accuracy of information Provided

I certify the information given in this application is true, complete, and accurate to the best of my knowledge and does not omit any material fact that would render the statement false, fictitious, or fraudulent because of the omission. I understand the information provided may be investigated and any false representation is sufficient cause for rejection of this application, or, if awarded loan repayment, I am liable for return of all awarded funds and, further, any false statement may be punished as a felony under 18 U.S.C. § 1001. I am aware any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986. I authorize any program to which I owe a service obligation to release information about that obligation to administrators of the NIFA VMLRP and other authorized Government officials.

Signature of Applicant ^Date

Public reporting for collection of information is estimated to average 2 hours, 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 current 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 NIFA, OGFM, 2312 East Bannister Road, Mail Stop 10,000, Kansas City, MO 64131, Attention Policy Section. Do not return the completed form to this address.

OMB No. 0524-0050

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