Dd2475 Form Example PDF Details

In this blog post, we'll provide an example of the dd2475 form. This form is used to collect information about a disability and how it affects the individual's ability to work. The purpose of this form is to help employers determine if an individual is eligible for accommodations under the Americans with Disabilities Act (ADA). We'll provide a brief overview of the ADA and how it applies to employers. We'll also provide some tips on how to complete the dd2475 form. Finally, we'll provide a link to a downloadable pdf version of the form. We hope you find this information useful!

QuestionAnswer
Form NameDd2475 Form Example
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow to fill out a 1750, dd 1750 example filled out, us army dd form 1750 sample, how to fill out 1750

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DOD EDUCATIONAL

LOAN REPAYMENT PROGRAM (LRP)

ANNUAL APPLICATION

CONTROL NO.

LOAN PROGRAM (X one)

ACTIVE DUTY LRP

HEALTH PROFESSIONALS LRP

SELECTED RESERVE LRP

OMB No. 0704-0152

OMB approval expires

Oct 31, 2009

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, Executive Services Directorate (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 USC 2171, 2173, 16301, 16302, and EO 9397, November 1943 (SSN).

PRINCIPAL PURPOSE: To administer the DoD Loan Repayment Program.

ROUTINE USES: Release is restricted to the Department of Education, to the U.S. Public Health Service, to public and private higher educational institutions, to financial institutions, to the Internal Revenue Service, to private bill collection agencies. The information provided may be used in computer matching programs within the DoD or with any other affected Federal Agency for verification to determine your eligibility and/or compliance with the benefit program requirements being applied for herein and to effect recovery of any improper payments made toward delinquent debts owed by a beneficiary or former beneficiary.

DISCLOSURE: Voluntary; however, failure to provide your Social Security Number may delay processing of your LRP application.

1.PERSONNEL OFFICE VERIFICATION (To be completed by the designated personnel officer)

a. FORWARD COMPLETED FORM TO THIS ADDRESS (Include ZIP Code)

b. VERIFYING OFFICIAL.

I certify that this servicemember has performed satisfactorily.

(1)NAME (LAST, FIRST, MIDDLE INITIAL)

(2) SIGNATURE

(3) DATE SIGNED

 

(YYYYMMDD)

 

 

2.SERVICEMEMBER DATA (To be completed by servicemember)

a.NAME (Last, First, Middle Initial)

c. SOCIAL SECURITY NO.

d. TELEPHONE NO. (Incl. Area Code)

 

 

 

e. E-MAIL ADDRESS

 

f. TOTAL OF PRIOR

 

 

PAYMENTS

 

 

 

b.ADDRESS (Street, City, State, and ZIP Code)

I authorize the release of my financial data by lender/holder to complete entries in Section 4.

g. SIGNATURE

h. DATE SIGNED

(YYYYMMDD)

 

 

 

3.LOAN DATA (To be completed by servicemember)

a.NAME ON THE LOAN (Last, First, Middle initial)

b.ORIGINAL DATE OF PROMISSORY NOTE (YYYYMMDD)

c. ORIGINAL LOAN AMOUNT

d. LOAN

 

OF

 

LOANS

 

 

 

 

 

e. LOAN ACCOUNT NUMBER

f. LOAN HOLDER NAME

g. LOAN HOLDER ADDRESS (Include ZIP Code)

h.TELEPHONE NUMBER (Include Area Code)

4.LENDER VERIFICATION (To be completed by loan holder)

a. LOAN IN DEFAULT (X one)

b. UNPAID PRINCIPAL BALANCE

c. OUTSTANDING BALANCE

d. ORIGINAL LOAN AMOUNT

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. NAME AND ADDRESS OF INSTITUTION WHERE PAYMENT IS TO BE

f. FEDERAL TAX IDENTIFICATION NO.

g. TYPE OF LOAN (See Instructions)

SENT (Include ZIP Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. IS THIS A CON-

i. LOAN INTEREST

j. LOAN FEES

 

 

 

 

 

SOLIDATED LOAN?

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

k.CERTIFYING OFFICER.

As an official of the holding institution, I verify that this information is correct and current. Copy of the promissory note is enclosed.

(1)NAME (Last, First, Middle Initial)

(2) TITLE

(3) SIGNATURE

(4)DATE SIGNED (YYYYMMDD)

FORWARD THIS FORM TO THE ADDRESS LISTED IN SECTION 1, BLOCK A.

5.REMARKS (Continue on back if necessary)

DD FORM 2475, NOV 2006

PREVIOUS EDITION IS OBSOLETE.

FormFlow/Adobe Designerl 7.0

5.REMARKS (Continued)

DD FORM 2475,

"DOD EDUCATIONAL LOAN REPAYMENT PROGRAM (LRP) ANNUAL APPLICATION"

INSTRUCTIONS

SECTION 1. PERSONNEL OFFICE VERIFICATION (To be completed by the designated personnel officer.)

1.a. - b. Self-explanatory.

SECTION 2. SERVICEMEMBER DATA (To be completed by servicemember.)

2.a. - e. Self-explanatory.

2.f. Enter the total amount of money that has been paid by the military under the Loan Repayment Program on your education loans.

2.g. - h. Self-explanatory.

SECTION 3. LOAN DATA

(To be completed by servicemember.)

3.a. Name as it appears on the promissory note. 3.b. - c. Self-explanatory.

3.d. Loan ___ of ___ Loans. A separate DD Form 2475 must be completed for each loan if Servicemember has more than one (1) loan. For example, loan 1 of 3 loans, loan 2 of 3 loans, and loan 3 of 3 loans.

3.e. Loan Account Number of the current loan holder (usually found on payment book or coupon or on promissory note).

3.f. - h. Identify the name, address, and telephone number of the institution that currently holds your loan. Please list any additional contact information in Section 5, Remarks.

SECTION 4. LENDER VERIFICATION (To be completed by loan holder.)

4.a. Mark X in the appropriate box. 4.b. Self-explanatory.

4.c. Principal plus interest, plus any fees. Please specifically list the fees in Section 5, Remarks.

4.d. Self-explanatory.

4.e. Complete this block only if different than the one listed in 3.f. and 3.g.

4.f. Loan holder must provide their Federal tax identification number for tax withholding.

4.g. Type of Loan. Select from list below: The loan must qualify under the Higher Education Act of 1965, Title 4, Parts B and E; the Health Education Assistance Loan under Part C, Title VII, Public Health Service Act; under Part B, Title VIII; Health Professional Loans that the SECDEF determines to be critical to meet wartime medical skill shortages; William D. Ford Federal Direct Loan; or any loan incurred for educational purposes made by a lender that is: (1) an agency or instrumentality of a State; (2) a financial or credit institution (including an insurance company) that is subject to examination and supervision by an agency or the United States or any State; or (3) from a pension fund or a non-profit private entity (subject to case-by-case review/approval by the Office of the Undersecretary of Defense for Personnel and Readiness (Military Personnel Policy) (Accession Policy) through each Service's Education Representatives).

4.h. If multiple loans have been consolidated, mark (X) "Yes" or "No" indicating consolidating action.

4.i. - k. Self-explanatory.

After completion and signature, the personnel records custodian will forward this form to the address listed in Section 1, block A.

SECTION 5. REMARKS.

Use this section to enter additional information that will assist in processing this application.

DD FORM 2475 (BACK), NOV 2006