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DD FORM 2475, - usa-federal-forms.com

(x c. in b. a. control no. loan type one) dod educational . form approved . active duty lrp . loan repayment program (lrp) omb no. 0704-0152 . health professionals lrp

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  Form, 4725, Dd form 2475

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Text of DD FORM 2475, - usa-federal-forms.com

LOAN TYPE (X one) CONTROL NO. DOD EDUCATIONAL Form Approved ACTIVE DUTY LRP LOAN REPAYMENT PROGRAM (LRP) OMB No. 0704-0152 HEALTH PROFESSIONALS LRP ANNUAL APPLICATION Expires May 31, 2000 SELECTED RESERVE LRP The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0152), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO EITHER OF THESE ADDRESSES. FORWARD YOUR FORM TO THE APPROPRIATE ADDRESS AS INDICATED IN THE INSTRUCTIONS ON BACK. PRIVACY ACT STATEMENT AUTHORITY: 10 USC 2171, 16301, 16302, and EO 9397, November 1943 (SSN). PRINCIPAL PURPOSE: To administer the DoD Loan Repayment Program. ROUTINE USES: Release is restricted to the Department of Education, to the Public Health Service, to public and private higher educational institutions, to financial institutions, to the Internal Revenue Service, to private bill collection agencies. The information provided may be used in computer matching programs within the DoD or with any other affected Federal Agency for verification to determine your eligibility and/or compliance with the benefit program requirements being applied for herein and to effect recovery of any improper payments made toward delinquent debts owed by a beneficiary or former beneficiary. DISCLOSURE: Voluntary; however, failure to provide your Social Security Number may delay processing of your LRP application. SECTION I - SERVICEMEMBER DATA (To be completed by servicemember) 1. LENDER a. NAME b. ADDRESS (Street, City, State, and ZIP Code) c. TELEPHONE NUMBER (Include Area Code) d. ACCOUNT NUMBER e. LOAN OF LOANS 2. SERVICEMEMBER a. TYPED OR PRINTED NAME (Last, First, Middle Initial) b. ADDRESS (Street, City, State, and ZIP Code) c. SOCIAL SECURITY NO. d. TELEPHONE NO. (Incl. Area Code) I authorize the release of my financial data by lender/holder to complete entries in SECTION III. e. SIGNATURE f. DATE SIGNED (YYYYMMDD) SECTION II - PERSONNEL OFFICE VERIFICATION (To be completed by personnel/unit records custodian) 3. UNIT OF ASSIGNMENT a. UNIT DESIGNATION b. ADDRESS (Street, City, State, and ZIP Code) c. TELEPHONE NUMBER (Include Area Code) d. LOAN ELIGIBILITY DATE 4. PERSONNEL/UNIT RECORDS CUSTODIAN a. TYPED OR PRINTED NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED (YYYYMMDD) SECTION III - LOAN STATUS CONFIRMATION (To be completed by loan holder) 5. LOAN DATA a. STATUS (X one) IN DEFAULT DEFERRED PAYMENTS BEING MADE b. ORIGINAL AMOUNT c. OUTSTANDING BALANCE d. INTEREST DUE (Not paid by DOE) YES NO e. DATA SHOWS CONSOLI-DATION (When multiple loans are involved) 6. LOANHOLDER DATA a. NAME c. ADDRESS (Street, City, State, and ZIP Code) b. TELEPHONE NUMBER (Include Area Code) 7. INSTITUTION WHERE PAYMENT IS TO BE SENT a. NAME c. ADDRESS (Street, City, State, and ZIP Code) b. TELEPHONE NUMBER (Include Area Code) 8. TYPE OF LOAN 9. ORIGINAL DATE OF NOTE (YYYYMMDD) 10. UNPAID PRINCIPAL BALANCE 11. INTEREST RATE 12. LOAN ACCOUNT NUMBER 13. CERTIFYING OFFICER. As an official of the holding institution, I verify that SECTION III information is correct and current. Copy of the promissory note(s) is enclosed. a. NAME (Last, First, Middle Initial) b. TITLE c. SIGNATURE d. DATE SIGNED (YYYYMMDD) (Please print or type) DD FORM 2475, MAY 1997 (EG) PREVIOUS EDITION IS OBSOLETE. Designed using Perform Pro, WHS/DIOR, May 97 14. REMARKS DD FORM 2475, "DOD EDUCATIONAL LOAN REPAYMENT PROGRAM (LRP) ANNUAL APPLICATION" INSTRUCTIONS SECTION I (To be completed by servicemember.) 1. a. LENDER NAME. Institution that made the original loan to the servicemember. Loans are often sold so that the current holder of the loan may not be the original lender of the loan. b. - c. Self-explanatory. d. LOAN ACCOUNT NUMBER (usually found on payment book or coupon or on promissory note). e. LOAN _____ OF _____ LOANS. If service-member has more than one (1) loan, a separate DD Form 2475 must be completed for each loan. Item will indicate the loan number; , loan 1 of 3 loans, loan 2 of 3 loans, or loan 3 of 3 loans. 2. Self-explanatory. After completion and signature, the servicemember will forward this form to the unit personnel records custodian or unit clerk. SECTION II (To be completed by the unit clerk or personnel records custodian.) 3. a. - c. Self-explanatory. d. Date this loan eligibility is payable (accession date plus 1 year). 4. Self-explanatory. After completion and signature, the personnel records custodian will forward this form to the address in item 1b. SECTION III (To be completed by loan holder.) (Current loan holder should complete this section.) 5. a. - d. Self-explanatory. e. DATA SHOWS CONSOLIDATION. If multiple loans have been consolidated, mark (X) "Yes" or "No" indicating consolidating action. 6. Self-explanatory. 7. Self-explanatory. 8. TYPE OF LOAN. Select from list below: The loan must qualify under the Higher Education Act of 1965, Title 4, Parts B and E; the Health Education Assistance Loan under Part C, Title VII, Public Health Service Act; under Part B, Title VIII; Health Professional Loans that the SECDEF determines to be critical to meet wartime medical skill shortages; or William D. Ford Federal Direct Loan. 9. - 12. Complete based on original loan data. 13. Self-explanatory. After completion and signature, the loan holder will forward form to the address in items 3a. and 3b. 14. Enter any additional information you believe is necessary. DD FORM 2475 (BACK), MAY 1997

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