First name last name, - Virginia Department of Health
Today’s date
Virginia Department of Health,
Office of Health Equity
Attn: Olivette Burroughs,
Health Workforce Specialist
109 Governor Street, Suite 714-West
Richmond, VA 23219
Dear Mrs. Burroughs:
This letter is to confirm/verify that Virginia State Loan Repayment Program recipient, Recipient’s Name is applying for the State of Virginia community match of up to $50,000.00 because the above name individual does not have a community match from his employer or anyone in the community; therefore, will receive $_________in state funds. Our signature below certifies that these state-matched funds are not designated for or from any other federal program. If approved, it is understood that the Virginia Department of Health- Office of Health Equity (VDH-OHE) will provide a match of $_________federal dollars to the above-named recipient. These funds provided by the VA- SLRP and the State of Virginia are to be used for "repayment of educational loans received" during the recipient’s medical training. (Please see VDH-OHE guidelines for details.) All funds are tax free (federal and community).
The federal match and state of Virginia funds that VDH-OHE will provide to Recipient’s Name is for the period of 2019-2020 application year. Renewal of this federal award is not guaranteed every year as it is based on available funding. We understand that an opportunity for a renewal award, if eligible, is also contingent upon the timely receipt of verification of employment forms.
Upon receipt of this form, the advisory committee will make a determination. Proof of debt reduction will be provided to VDH-OHE within sixty (60) days of payment.
_________________________________________Date _________________________
Applicant’s signature
__________________________________________
Virginia Department of Health, Office of Health Equity
Organization’s Certifying Officer Date
____________________________
Certifying Officer’s Signature
Instructions-
Please do not include this page (page 2) as part of the application packet as it is for information only.
Enter date at top (the date that you are completing the form)
Only complete this cash match template if….
- The applicant does not have a cash match and wishes to apply for State matching funds. Please complete the cash match template for State matching funds (page 1). If the applicant has a community match from an employer etc., please complete the standard cash match letter at:
Only make changes as follows:
Recipient’s Name - Enter recipient’s name
________________________Date- Applicant Sign and date (after you print)
Applicant’s signature
Leave all money related fields blank
$______________- Leave blank
Note: Funds are not guaranteed, are determined based on availability of funding, eligibility and selection by an advisory committee.
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