FY-2013 Student Loan Repayment Program (SLRP) Application …



FY-2013 Student Loan Repayment Program (SLRP) Application Form

To be eligible for a student loan repayment incentive, your loan, occupational series, and grade level must qualify, and you must meet all eligibility requirements in USAID General Notice, “Announcement of FY-2013 Student Loan Repayment Program Open Season,” dated July 2013 and the FY-2013 USAID SLRP Implementation Guidelines. Please review this application carefully. If you believe you meet all eligibility requirements, please complete this application form. Your application form and supporting loan documentation must be received by the SLRP Team in the Office of Human Resources by Friday, August 16, 2013. All sections of this form must be filled out. Incomplete applications will not be processed. Your responses will determine if you meet eligibility requirements for a SLRP incentive. Please contact the SLRP Team at SLRP@ if you have questions.

You must provide a copy of your loan documents as part of the application process. Lender documentation must identify you as the borrower and include proof of the following: type of outstanding qualifying federally insured loan; current outstanding balance of the loan and date of current loan balance; status of loan account to determine that payments are current; and payments credited to your account during the past year.

|Last Name: | |

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|First Name: | |

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|Middle Initial: | |

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|Last 4 Digits of SSN#: | |

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|Bureau/Office/Mission: | |

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|Office Phone Number: | |

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|Home/Cell Phone Number: | |

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|Work Email Address: | |

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|Personal Email Address: | |

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|Area #1 Personal Eligibility (Type of Appointment) |

|Are you serving on a career or career-type appointment in the competitive or excepted service? Employees whose appointments are for a limited period of time and who do not|

|have conversion eligibility are not in career-type appointments. Untenured Foreign Service Officers and Civil Service employees serving in excepted appointments with |

|conversion to career or career conditional appointments are in career-type appointments. Civil Service career employees who are on a Foreign Service Limited non-career |

|appointment with reemployment rights are also considered in a career-type appointment. |

| Yes If your answer is Yes, check Appointment Type | |

| |No If your answer is No, you are not eligible for the SLRP. |

|Appointment Type |

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|GS |

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|FS |

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|PMF |

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|FS Limited with Reemployment Rights |

|Area #2 Position Eligibility (Grade and Pay Plan) |

|If you are Foreign Service complete Section 2(a) |

|If you are Civil Service or PMF complete Section 2(b) |

|2(a) Foreign Service (Includes all Backstops and Geographic Locations) |

|Is your current FS salary class FP/FO-03 or below? |

| Yes (If your answer is yes, indicate FS Salary Class and FS Backstop) | No (If you answer is no and your current FS salary class is above FP/FO-03, you do |

| |not qualify for the SLRP. |

|FS Salary Class | |FS Backstop |

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|FP/FO-06 | |      |

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|FP/FO-05 | | |

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|FP/FO-04 | | |

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|FP/FO-03 | | |

|2(b) Civil Service (All GS employees including Presidential Management Fellows. |

|Is your official position of record in one of the designated occupational series or grade levels listed below? |

|If you are a PMF, please indicate your Official Position Title of your targeted position and attach a copy of your appointment letter. |

| Yes If your answer is Yes, indicate your Occupational Series, Current Grade Level, and| |

|Official Position Tittle. |No If your answer is No, you are not eligible for the SLRP. |

| |Current Grade Level | |

|GS Occupational Series | |Official Position Title |

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|0201, Human Resources Management, GS-13 and below; | | |

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|0203, Human Resources Assistant, GS-8 and below; | | |

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|0343, Management and Program Analyst, GS-13 and below; | | |

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|0560, Budget Analyst, GS-13 and below; | | |

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|0601, General Health Science GS-13 and below; | | |

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|0685, Public Health Program Specialist, GS-13 and below; and | | |

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|1102, Contracting, GS-13 and below; | | |

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|Area #3 Federal Loan Eligibility |

|I have a qualifying, federally-insured student loan for completed studies, and my studies are from an accredited school. |

|No- If your answer is no, you are not eligible for the SLRP |

|Yes- If your answer is yes, please check the type of loan you qualify under, as well as provide the lender name, payment address, account number, and current principal |

|balance. |

|Type of Loan – Check one loan |Lender Name, Payment Address |Current Outstanding Balance (Principal Only) |

|Do not list private loans in this section. |and Account Number | |

|Federal Family Education Loans (FFEL) |Lender Name |      |

|Subsidized Federal Stafford Loans | | |

|Unsubsidized Federal Stafford Loans |      | |

|Federal Consolidation Loans | | |

|Federal PLUS Loans – (Must be in employee’s name) | | |

|William D. Ford Direct Loan Program (Direct Loans) | | |

|Direct Subsidized Stafford Loans | | |

|Direct Unsubsidized Stafford Loans | | |

|Direct Subsidized Consolidation Loans | | |

|Direct Unsubsidized Consolidation Loans | | |

|Direct PLUS Loans – (Must be in employee’s name) | | |

|Federal Perkins Loan Program | | |

|National Defense Student Loans | | |

|National Direct Student Loans | | |

|Perkins Loans | | |

|Loans for Disadvantaged Students (LDS) | | |

|Primary Care Loans (PCL) | | |

|Nursing Student Loans (NSL) | | |

|Health Professions Student Loans (HPSL) | | |

|Health Education Assistance Loans (HEAL) | | |

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| |Lender Payment Address | |

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| |Account Number | |

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|1. Is your qualifying student loan in default status? |

| Yes If your answer is yes, you are not eligible for the SLRP. | No |

|(Your loan must be out of default status to participate in the FY-2013 SLRP. | |

|2. Have you received a SLRP incentive from another federal agency(s)? |

| Yes If your answer is yes, please provide the following information: the number of incentives; the dates | No |

|received; the amount(s) paid to the lending institutions; and the name of the agency(s). | |

|Number of Incentives: |      |

|Dates Received: |      |

|Amount Paid: |      |

|Name of Agency: |      |

|3. Are you a past participant in USAID’s SLRP Program? |

| Yes. If your answer is yes, indicate in which fiscal years you received a SLRP incentive and indicate the | No |

|amount of the lump sum SLRP incentive | |

|FY 2005, indicate amount of lump sum incentive       |FY 2010, indicate amount of lump sum incentive       |

|FY 2008, indicate amount of lump sum incentive       |FY 2011, indicate amount of lump sum incentive       |

|FY 2009, indicate amount of lump sum incentive       |FY 2012, indicate amount of lump sum incentive       |

|4. Did you receive a split payment from the Agency on two lenders/loans in FY 2012? |

| Yes If your answer is yes, you must submit documentation for twelve months of payment history between July 1,| No |

|2012, and June 30, 2013, on BOTH loans. | |

|5. Are you applying for student loan repayment incentives for studies currently underway but not yet completed? |

| Yes – If your answer is yes, you are not eligible for the SLRP. Please refer to the | No |

|Tuition Assistance Program (TAP) for assistance with ongoing studies. | |

|6. Do you have private student loans? (Do not list federally insured loans here.) |

| Yes - If your answer is yes, indicate name of lender(s), loan type(s) and amount(s) owed| No |

|in the space below. If you combined balances for private and federally insured loans | |

|together in the first question under this section, you need to return to that question | |

|and make the appropriate changes. | |

|Name of Lender(s)       |

|Loan Type(s)       |Amount(s) Owed       |

|Name of Lender(s)       |

|Loan Type(s)       |Amount(s) Owed       |

|7. Have you been on Leave-Without-Pay (LWOP) status for the entirety of the annual Open Season period from July 10, 2013, to August 16, 2013? |

| Yes - If your answer is yes, you are not eligible for the SLRP. | No |

|8. Is your performance/conduct record free of any disciplinary actions resulting in suspension within the past two years? |

| Yes | No |

|For Foreign Service: I received a report card of “B” or above, and I have not been referred to the Performance Standards Board within the last two performance cycles (2011 |

|and 2012). If you are a new employee and have not yet received an annual performance rating, please respond “Not yet rated” to this question. |

| Yes | Not yet rated | No |

|Comments:       |

| |

| |

|For Civil Service: My last annual performance rating was “Fully Successful” or higher. If you are a new employee and have not yet received an annual performance rating, |

|please respond “Not yet rated” to this question. |

| Yes | Not yet rated | No |

|Comments:       |

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|Service Commitment |

|As a first time applicant, I understand that, if I am approved to receive a SLRP repayment incentive, I must sign a service agreement to work for three years as a |

|direct-hire employee with USAID. If I received previous SLRP repayment incentive(s), I must sign an additional one-year extension to my existing service agreement or be |

|subject to a new three-year service agreement commitment, if previous agreement commitments have expired. |

|I agree to this service commitment with USAID. My signed service agreement is attached to this application form. |

| |Date       |

|Signature       | |

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|Your application form will be reviewed by the OHR SLRP Team. Your application will not be processed without a copy of your supporting loan documentation. The OHR SLRP Team|

|must receive copies of all required application materials and supporting loan documentation by Friday, August 16, 2013. Applications that are incomplete will not be |

|processed. Employees who are determined to be ineligible will be advised by email of the reason for disqualification. |

|Questions? Contact the OHR SLRP Team at SLRP@. |

PRIVACY ACT STATEMENT

Authority: 22 U.S.C. 2651a; 5 U.S.C. 301; 5 U.S.C. 5379, and E.O. 9397 for the SSN.

Principal Purpose: To collect information to determine if you are eligible to participate in the Student Loan Repayment Program (SLRP).

Routine Uses: The personal information and SSN are used by the U.S. Agency for International Development (USAID) to determine eligibility for the Student Loan Repayment Program, to maintain administrative records, to perform other administrative functions inherent in the administration of this program, and to make payments on your behalf. This information will be made available to the Internal Revenue Service for tax and withholding purposes and to the Office of Personnel Management. Additionally, these records, or information there-from, may also be used within USAID for study purposes, such as projection of staffing needs, and/or creation of non-identifiable statistical data for reports to other Federal agencies and Congress.

Disclosure: Disclosure is voluntary for both personal information and the last four digits of your SSN, but failure to provide certain information may result in denial of your application and no SLRP incentive payment(s) made on your behalf.

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