FLORIDA SAFETY DECISION MAKING FRAMEWORK



|APPLICATIONS WILL BE ACCEPTED ELECTRONICALLY AT LOAN.FORGIVENESS@ FROM 8:00 AM ET, April 15, 2015 THROUGH 5:00 PM ET, May 29, 2015. APPLICATIONS RECEIVED |

|BY MAIL WILL NOT BE PROCESSED. If any information is missing, the application will be denied as incomplete. Please make sure lender information is correct. |

|SEND NOW as an attachment to your completed application: |

|A legible copy of your College Diploma/Degree or official school transcript showing Social Work as your area of study. |

|A legible copy of your Most Recent Performance Evaluation. |

|A legible copy of your current job description. |

|A legible copy of your lender statement showing proof of loan including: your name, account number, loan balance and lender’s payment remittance address. |

| |

| |

|YOUR APPLICATION must be received by 5:00 PM, ET, Friday, May 29, 2015. The application must be signed by you and your Supervisor or the Agency Head and submitted to the |

|following email address: loan.forgiveness@. |

|It is your responsibility to ensure accurate personal information is provided and updated. If accurate information is not entered your application will be denied. Please|

|complete the application in its entirety. |

| |

|APPLICANT INFORMATION |

| |First Name:       |Last Name:       |Middle Initial:       |

|Current Name: | | | |

|Name at time of Student Loan: |First Name:       |Last Name:       |Middle Initial:       |

|If different when you applied for your student loan. |

|Social Security Number       | |

|Mailing Address:       |Apartment Number:       |

|City:       |State:       |County:       |Zip Code:       |

|Home Number:       |Work Number:       |

|E-mail Address:       | |

|What year did you complete your Social Work degree?       |

|Where do you work? |Region: |Circuit: |County:       |

|Do you work for DCF? If Yes, proceed to Section II. If No, proceed to Section III. |

|II. DEPARTMENT OF CHILDREN AND FAMILIES EMPLOYEES |

| |

|Position Number:       |

|Class Title: |If other please specify:       |

|III. COMMUNITY BASED CARE (CBC) OR PROVIDER EMPLOYEES |

|What is your position title? |If other please specify:       |

|CBC or Contract Provider Agency Name:       |

|CBC or Contract Provider Agency Address:       |

|CBC or Contract Provider Agency Human Resources or Personnel Office Contact, Name & Position:       |

|CBC or Contract Provider Agency Human Resources or Personnel Office Contact Telephone Number:       |

|Current Supervisor’s Name:       |Current Supervisor’s Contact Number:       |

|Your Last Performance Evaluation Rating (copy attached):       | |

|IV. LOAN INFORMATION |

|This section lists the loans you took to complete your post-secondary education in social work AND to which you want this grant applied. |

|Please complete for each loan you currently owe AND that you want this award applied to. |

|If this area is incomplete, your application will not be processed. |

| |

|Loan #1 |

|Post-Secondary Institution (college or university):       |

|Current Loan Holder:       |Loan Account Number:       |

|Loan Holder Mailing Address:       |

|Loan Holder Remittance Address:       |

|Loan Holder Federal Vendor ID#:       |

|Loan Holder Customer Service Phone Number:       |

|Degree Type (copy of diploma attached):       |

|Degree Area:       |

|Amount Borrowed:       |

|Loan Balance:       |

|Date Loan Started:       |

| |

|Loan #2 |

|Post-Secondary Institution (college or university):       |

|Current Loan Holder:       |Loan Account Number:       |

|Loan Holder Mailing Address:       |

|Loan Holder Remittance Address:       |

|Loan Holder Federal Vendor ID#:       |

|Loan Holder Customer Service Phone Number:       |

|Degree Type (copy of diploma attached):       |

|Degree Area:       |

|Amount Borrowed:       |

|Loan Balance:       |

|Date Loan Started:       |

|Loan #3 |

|Post-Secondary Institution (college or university):       |

|Current Loan Holder:       |Loan Account Number:      |

|Loan Holder Mailing Address:       |

|Loan Holder Remittance Address:       |

|Loan Holder Federal Vendor ID#:       |

|Loan Holder Customer Service Phone Number:       |

|Degree Type (copy of diploma attached):       |

|Degree Area:       |

|Amount Borrowed:       |

|Loan Balance:       |

|Date Loan Started:       |

|IV. AGENCY CERTIFICATION |

As authorized by s.402.404 (2), F.S., as the employing agency, (specify agency)       , I certify that this applicant is employed by a child welfare agency in one of the specified positions pursuant to s. 402.404(2), F.S., and has been approved by the agency as meeting a high level of performance based on his or her personnel evaluation as required by law for participation in this program.

Child Protection and Child Welfare Personnel Student Loan Forgiveness Program, s. 402.404(2), F.S.—

(2) To be eligible for the program, a candidate must:

(a) Be employed by the department as a child protective investigator or a child protective investigation supervisor or be employed by a community-based care lead agency or subcontractor as a case manager or case manager supervisor;

(b) Be determined by the department or his or her employer to have a high level of performance based on his or her personal evaluation; and

(c) Have graduated from an accredited social work program with either a bachelor’s degree or a master’s degree in social work.

Supervisor or Agency Head (SIGNATURE) Date

(PRINT NAME) Phone Number

|V. APPLICANT CERTIFICATION |

Top of Form 1

By submitting this application, I certify that to the best of my knowledge and belief, the information contained on this application is true, complete, and correct. I give permission to my employer, The Florida Department of Children and Families, The Florida Department of Education, my post-secondary institution, and lender to complete certification of required information. I understand that the application must be signed by me and by my supervisor, or the agency head, to be considered complete. If this application is not received by 5:00 PM, ET May 29, 2015 or is not signed by me and my Supervisor or Agency Head, my application will be deemed incomplete and will be denied.

I further attest that the student loan, for which I am requesting this grant, was used to cover allowable expenses as specified in law (e.g., tuition, books, living expenses, etc.) associated with the attainment of my social work degree. If I change jobs, I understand that I must notify the Department at the following e-mail address loan.forgiveness@.

I acknowledge if a student loan payment is made to a lender on my behalf, the total amount of the payment will be considered reportable income for income tax purposes.

Applicant Signature Date

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download