ࡱ> z|wxy)` Jbjbj 12///8201DGjN4.:j:::<< <hhhhhhh$+lhnh=<<"==h:: j@@@=X::h@=h@@6RY[:B4 鰇/7>X2Zb j0GjNZQo>Qo8[Qo[<>*=,@V=$z=e<<<hh@X<<<Gj====(//  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  HYPERLINK "mailto:SLRP@usaid.gov" SLRP@usaid.gov 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:  FORMTEXT      First Name:  FORMTEXT      Middle Initial:   FORMTEXT      Last 4 Digits of SSN#:  FORMTEXT      Bureau/Office/Mission:  FORMTEXT      Office Phone Number:  FORMTEXT      Home/Cell Phone Number:  FORMTEXT      Work Email Address:  FORMTEXT      Personal Email Address:  FORMTEXT      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. FORMCHECKBOX  Yes If your answer is Yes, check Appointment Type   FORMCHECKBOX  No If your answer is No, you are not eligible for the SLRP. Appointment Type  FORMCHECKBOX GS  FORMCHECKBOX FS  FORMCHECKBOX PMF  FORMCHECKBOX 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? FORMCHECKBOX  Yes (If your answer is yes, indicate FS Salary Class and FS Backstop) FORMCHECKBOX  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  FORMCHECKBOX  FP/FO-06  FORMCHECKBOX  FP/FO-05  FORMCHECKBOX  FP/FO-04  FORMCHECKBOX  FP/FO-03FS Backstop  FORMTEXT      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. FORMCHECKBOX  Yes If your answer is Yes, indicate your Occupational Series, Current Grade Level, and Official Position Tittle.  FORMCHECKBOX  No If your answer is No, you are not eligible for the SLRP.  GS Occupational Series  FORMCHECKBOX 0201, Human Resources Management, GS-13 and below;  FORMCHECKBOX 0203, Human Resources Assistant, GS-8 and below;  FORMCHECKBOX 0343, Management and Program Analyst, GS-13 and below;  FORMCHECKBOX 0560, Budget Analyst, GS-13 and below;  FORMCHECKBOX 0601, General Health Science GS-13 and below;  FORMCHECKBOX 0685, Public Health Program Specialist, GS-13 and below; and  FORMCHECKBOX 1102, Contracting, GS-13 and below; Current Grade Level  FORMTEXT       Official Position Title  FORMTEXT       Area #3 Federal Loan EligibilityI have a qualifying, federally-insured student loan for completed studies, and my studies are from an accredited school.  FORMCHECKBOX  No- If your answer is no, you are not eligible for the SLRP  FORMCHECKBOX  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 Do not list private loans in this section.Lender Name, Payment Address and Account NumberCurrent Outstanding Balance (Principal Only) Federal Family Education Loans (FFEL)  FORMCHECKBOX Subsidized Federal Stafford Loans  FORMCHECKBOX Unsubsidized Federal Stafford Loans  FORMCHECKBOX Federal Consolidation Loans  FORMCHECKBOX Federal PLUS Loans (Must be in employees name) William D. Ford Direct Loan Program (Direct Loans)  FORMCHECKBOX Direct Subsidized Stafford Loans  FORMCHECKBOX Direct Unsubsidized Stafford Loans  FORMCHECKBOX Direct Subsidized Consolidation Loans  FORMCHECKBOX Direct Unsubsidized Consolidation Loans  FORMCHECKBOX Direct PLUS Loans (Must be in employees name) Federal Perkins Loan Program  FORMCHECKBOX National Defense Student Loans  FORMCHECKBOX National Direct Student Loans  FORMCHECKBOX Perkins Loans  FORMCHECKBOX Loans for Disadvantaged Students (LDS)  FORMCHECKBOX Primary Care Loans (PCL)  FORMCHECKBOX Nursing Student Loans (NSL)  FORMCHECKBOX Health Professions Student Loans (HPSL)  FORMCHECKBOX Health Education Assistance Loans (HEAL) Lender Name  FORMTEXT       FORMTEXT       Lender Payment Address  FORMTEXT      Account Number  FORMTEXT       1. Is your qualifying student loan in default status?  FORMCHECKBOX  Yes If your answer is yes, you are not eligible for the SLRP. (Your loan must be out of default status to participate in the FY-2013 SLRP.  FORMCHECKBOX  No 2. Have you received a SLRP incentive from another federal agency(s)?  FORMCHECKBOX  Yes If your answer is yes, please provide the following information: the number of incentives; the dates received; the amount(s) paid to the lending institutions; and the name of the agency(s).   FORMCHECKBOX  No Number of Incentives: FORMTEXT      Dates Received: FORMTEXT      Amount Paid: FORMTEXT      Name of Agency: FORMTEXT      3. Are you a past participant in USAID s SLRP Program?  FORMCHECKBOX  Yes. If your answer is yes, indicate in which fiscal years you received a SLRP incentive and indicate the amount of the lump sum SLRP incentive  FORMCHECKBOX  No  FORMCHECKBOX FY 2005, indicate amount of lump sum incentive  FORMTEXT        FORMCHECKBOX FY 2010, indicate amount of lump sum incentive  FORMTEXT        FORMCHECKBOX FY 2008, indicate amount of lump sum incentive  FORMTEXT       FORMCHECKBOX FY 2011, indicate amount of lump sum incentive  FORMTEXT       FORMCHECKBOX FY 2009, indicate amount of lump sum incentive  FORMTEXT        FORMCHECKBOX FY 2012, indicate amount of lump sum incentive  FORMTEXT      4. Did you receive a split payment from the Agency on two lenders/loans in FY 2012? FORMCHECKBOX  Yes If your answer is yes, you must submit documentation for twelve months of payment history between July 1, 2012, and June 30, 2013, on BOTH loans.  FORMCHECKBOX  No 5. Are you applying for student loan repayment incentives for studies currently underway but not yet completed? FORMCHECKBOX  Yes If your answer is yes, you are not eligible for the SLRP. Please refer to the Tuition Assistance Program (TAP) for assistance with ongoing studies. FORMCHECKBOX  No6. Do you have private student loans? (Do not list federally insured loans here.)  FORMCHECKBOX  Yes - If your answer is yes, indicate name of lender(s), loan type(s) and amount(s) owed 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. FORMCHECKBOX  NoName of Lender(s)  FORMTEXT      Loan Type(s)  FORMTEXT       Amount(s) Owed  FORMTEXT      Name of Lender(s)  FORMTEXT      Loan Type(s)  FORMTEXT       Amount(s) Owed  FORMTEXT      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? FORMCHECKBOX  Yes - If your answer is yes, you are not eligible for the SLRP. FORMCHECKBOX  No8. Is your performance/conduct record free of any disciplinary actions resulting in suspension within the past two years? FORMCHECKBOX  Yes  FORMCHECKBOX  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). 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FORMCHECKBOX  Yes  FORMCHECKBOX  Not yet rated  FORMCHECKBOX  NoComments:  FORMTEXT        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.  FORMCHECKBOX  Yes  FORMCHECKBOX  Not yet rated  FORMCHECKBOX  NoComments:  FORMTEXT        Service CommitmentAs 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.  Signature  FORMTEXT       Date  FORMTEXT       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  HYPERLINK "mailto:SLRP@USAID.GOV" SLRP@USAID.GOV.  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. 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