ࡱ>    _ (bjbj RL5\5\`zz8>lnO$($$$&B2',^'ENGNGNGNGNGNGN$Q>TkNv'&&"v'v'kN$$(ON/N/N/v'$$ENN/v'ENN/N/DI$W|Ay'FG,1N>O0nOG(TD(TXIIHTMIv'v'N/v'v'v'v'v'kNkN+|v'v'v'nOv'v'v'v'Tv'v'v'v'v'v'v'v'v'z> : APPLICATIONS WILL BE ACCEPTED ELECTRONICALLY AT  HYPERLINK "mailto:LOAN.FORGIVENESS@MYFLFAMILIES.COM" LOAN.FORGIVENESS@MYFLFAMILIES.COM 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 lenders 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@myflfamilies.com. 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 Current Name:First Name:  FORMTEXT      Last Name:  FORMTEXT      Middle Initial:  FORMTEXT      Name at time of Student Loan:First Name:  FORMTEXT      Last Name:  FORMTEXT      Middle Initial:  FORMTEXT      If different when you applied for your student loan. Social Security Number  FORMTEXT      Mailing Address:  FORMTEXT      Apartment Number:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      County:  FORMTEXT      Zip Code:  FORMTEXT      Home Number:  FORMTEXT      Work Number:  FORMTEXT      E-mail Address:  FORMTEXT      What year did you complete your Social Work degree?  FORMTEXT      Where do you work? Region:  FORMDROPDOWN Circuit:  FORMDROPDOWN County:  FORMTEXT      Do you work for DCF?  FORMDROPDOWN  If Yes, proceed to Section II. If No, proceed to Section III.  II. DEPARTMENT OF CHILDREN AND FAMILIES EMPLOYEES Position Number:  FORMTEXT      Class Title:  FORMDROPDOWN If other please specify:  FORMTEXT       III. COMMUNITY BASED CARE (CBC) OR PROVIDER EMPLOYEESWhat is your position title?  FORMDROPDOWN  If other please specify:  FORMTEXT      CBC or Contract Provider Agency Name:  FORMTEXT      CBC or Contract Provider Agency Address:  FORMTEXT      CBC or Contract Provider Agency Human Resources or Personnel Office Contact, Name & Position:  FORMTEXT      CBC or Contract Provider Agency Human Resources or Personnel Office Contact Telephone Number:  FORMTEXT      Current Supervisor s Name:  FORMTEXT      Current Supervisor s Contact Number:  FORMTEXT      Your Last Performance Evaluation Rating (copy attached):  FORMTEXT       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. 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AGENCY CERTIFICATION As authorized by s.402.404 (2), F.S., as the employing agency, (specify agency)  FORMTEXT       , 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  HYPERLINK "mailto:loan.forgiveness@myflfamilies.com" loan.forgiveness@myflfamilies.com. 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. 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