LNFVGAP Loan Forgiveness Application - NCSEAA
LNFVGAP
Loan Forgiveness Application
NCSEAA Loan Forgiveness Programs
SECTION 1. Borrower Request for Loan Forgiveness
Name: ______________________________________________
NCSEAA PID#: ________________
Address: _____________________________________________
Phone#: (____) _________________
(PO Box, Street)
__________________ ______
City
State
___________
Email: ________________________
Zip Code
Loan Program Name:______________________________________________________________________
(Name of loan you received from the NCSEAA.)
Employer Name:_________________________________________________________________________
Employer Address: _____________________________________________________________________
Position Title: ____________________________________
? Full-time ? Half-time ? Part-time
I request my obligation to the State of North Carolina be repaid through loan forgiveness. I authorize my
employer to provide information to the NCSEAA about the dates of my employment, the position I hold, and
my full-time/part-time status as needed to qualify for loan forgiveness of my NCSEAA loan.
_____________________________________________________
______/______/______
Signature of Borrower
Date (MM/DD/YYYY)
SECTION 2. Certification of Employment (To be completed by Human Resources or an authorized official)
Start date of Employment: ______/______/______
Type: ? Full-time ? Half-time ? Part-time
Date (MM/DD/YYYY)
End date of Employment: ______/______/______
(If applicable)
Date (MM/DD/YYYY)
Type: ? Full-time ? Half-time ? Part-time
Was there any unpaid leave of absence during this period? No ? Yes* ?
*If yes, please attach explanation and include dates of absence(s).
Employee¡¯s Position Title: ________________________________________________________________
If an Educator: Subject taught:_____________________________________________________________
If a Nurse: ? LPN ? RN ? FNP ? CRNA ? Nurse Educator ? Other __________________
I attest the foregoing information is true and correct to the best of my knowledge.
________________________________________
______/______/______
Signature of Official
Date (MM/DD/YYYY)
_______________________________________________________________________________________________
Name and Title (Please type or print)
_____________________________________________________
Name of Employing Agency
____________________________________
Mailing Address (PO Box, Street)
____________________________
Telephone Number
________________________
City
_______
__________
State
Zip Code
___________________________________________________________
Employer Email Address
Please direct questions to Repayment Services at (800) 700-1775, Option 1 RETURN THIS
FORM TO: REPAY@NCSEAA.EDU or UPLOAD TO MYPORTAL.NCSEAA.EDU.
INCOMPLETE FORMS ARE DENIED.
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