The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0152). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. FORWARD YOUR FORM TO THE ADDRESS LISTED IN SECTION 1, BLOCK a.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2171, Education Loan Repayment Program: Enlisted Members on Active Duty in Specified Military Specialties; 2173, Education
Loan Repayment Program: Commissioned Officers in Specified Health Professions; 16301, Education Loan Repayment Program: Members of Selected
Reserve; 16302, Education Loan Repayment Program: Health Professions Officers Serving in Selected Reserve with Wartime Critical Medical Skill
Shortages; 16303, Loan Repayment Program: Chaplains Serving in the Selected Reserve, and E.O. 9397, Social Security Number (SSN).
PRINCIPAL PURPOSE(S): In completing this form, you are requesting your Military Service to pay a portion of your student loan(s). The information you provide will be reviewed by Military Service personnel record custodians to verify that you meet eligibility requirements. This form will then be forwarded to the lender that you identify for verification of the loan amount and status. The form is returned to the Service finance office to make the annual payment to your lender. Collected information is covered by the Applicable Military Service System of Records Notice (SORN) for the Official Military Personnel File or Military Records Jacket. These links can be found at: http://dpclo.defense.gov/privacy/SORNs/component/DOD_Component_Notices.html.
ROUTINE USE(S): To the lender (Department of Education, U.S. Public Health Service, or other financial institution) you identify so that the loan amount and status can be verified. The lender returns the completed form to your unit for additional processing. To the Internal Revenue Service for the purpose of reporting taxable income, and to the credit reporting agencies to assist in the recovery of any improper payments made toward delinquent debts owed by a beneficiary or former beneficiary. The DoD Blanket Routine Uses found at http://privacy.defense.gov/blanket_uses.shtml may apply to this collection.
DISCLOSURE: Voluntary. However, if the requested information is not provided, DoD will not be able to verify the loan amount or status and make the annual payment you are requesting. Your Social Security Number (SSN) is used to ensure accuracy of data involving the specified individual applicant. If you do not provide your SSN, processing of your application may be delayed.
OFFICIAL MILITARY PERSONNEL FILES:
Air Force: http://dpclo.defense.gov/privacy/SORNs/component/airforce/F036_AF_PC_C.html
Army National Guard: http://dpclo.defense.gov/privacy/SORNs/component/army/A0600-8-104b_NGB.html
Marine Corps: http://dpclo.defense.gov/privacy/SORNs/component/usmc/M01070-6.html
1.PERSONNEL OFFICE VERIFICATION (To be completed by the designated personnel officer)