Service Verificati Service Verification

NIFA Veterinary Medicine

Loan Repayment Program (VMLRP)

SERVICE VERIFICATION National Institute of Food and Agriculture

US Department of Agriculture

OMB No. 0524-0050

Form Approved For Use Through XX/XX/XXXX

Instructions: Complete below sections and return the completed form to NIFA via the Box.com account, or other secure electronic submission system as communicated by USDA staff, set up by your Grants Management Specialist (GMS). Current account statement(s) for each servicer reflecting VMLRP loan payments to your account(s) during a service year is required with every October service verification submittal. These account statement(s) may be requested more frequently as needed. Failure to enclose required service verification and account statement(s) will delay payments to servicers on your behalf as well as reimbursement of tax payments.

Section 1. General Information
VMLRP Participant Name:
Shortage Type:	Type I: Private Practice (80% FTE commitment) Type II: Private Practice – Rural Area (minimum 30% to maximum 80% FTE commitment) Type III: Public Practice (minimum 49% to maximum 80% FTE commitment)
Shortage Identification Code:
Quarter of Service:

Section 2. Veterinary Service Instruction: Review the shortage nomination form, included with your award package, before answering the following questions.

1. Have you: 1) worked under supervision or provided self-service during the service period reported in Section 1, 2) not incurred leave-without-pay preventing you from performing services and activities required by your applicable shortage situation, and 3) not terminated employment during the service period reported in Section 1?

• Yes

• No

Provide an explanation for a "no" response:

2. Have you performed services and activities in the counties, and for the relevant species and/or stakeholders, required by your applicable shortage situation nomination document during the service period reported in Section 1?

• Yes

• No

If no, what percentage of hours have you completed this quarter? ___________

Provide an explanation for a "no" response:

Section 3: Change of Information

If any of the information below has changed in the past three months, please check the box next to the item, and refer to the table below for next steps. This information must be kept current for proper processing of your award.

• Loan Servicer or Account Number

• Bank Account

• Address

• Legal Name

• Employment

• Loan account is paid in full.

• Loan balance is low and this quarter’s VMLRP payment will pay loan account in full.

Loan Servicer or Account Number change	Upload to Box.com, or other secure electronic submission system as communicated by USDA staff, the welcome letter from your new servicer with the servicer’s name, and your name, address, and complete account number.
Bank Account change	Upload to Box.com, or other secure electronic submission system as communicated by USDA staff, a new ACH form.
Address change	Upload to Box.com, or other secure electronic submission system as communicated by USDA staff, a new ACH form.
Legal Name change	Upload to Box.com, or other secure electronic submission system as communicated by USDA staff, a new ACH form & a copy of the legal document authorizing the change (i.e. marriage license, divorce decree, court order).
Employment change	Complete Section 8 of Application Part 1_Program and upload to Box.com, or other secure electronic submission system as communicated by USDA staff.
Loan account is paid in full	Contact the Awards Management Division (AMD) at VMLRP@usda.gov.
Loan balance is low and this quarter’s VMLRP payment will pay loan account in full	Obtain a 30-day pay off statement from your servicer and upload to Box.com, or other secure electronic submission system as communicated by USDA staff. Thirty-day pay off statements account for interest that will accrue between today’s date and the estimated payment date.

Section 4. Certification of Services and Hours Provided I certify the services I have provided under the VMLRP agreement I have signed comply with applicable federal, state and local laws, and to the best of my knowledge none of the services provided were illegal veterinary services for which funding is prohibited by federal law. I further certify the information provided herein regarding services or activities provided under my VMLRP agreement is accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties as identified in U.S. Code, Title 18, Section 1001.

Clinic Name Clinic Address, City, State, & Zip Code

Print Name Signature Date

Phone Number Email Address

Public reporting for collection of information is estimated to average 15 minutes, 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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