## 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

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.

d. LOAN OF LOANS 

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

a. NAME (Last, First, Middle Initial)

c. SOCIAL SECURITY NO. b. ADDRESS (Street, City, State, and ZIP Code)

d. TELEPHONE NO. (Incl. Area Code)

g. SIGNATURE h. DATE SIGNED (YYYYMMDD)



### 4. LENDER VERIFICATION (To be completed by loan holder) 3. LOAN DATA (To be completed by servicemember)

a. LOAN IN DEFAULT (X one) b. UNPAID PRINCIPAL BALANCE c. OUTSTANDING BALANCE

YES NO f. LOAN HOLDER NAME

g. LOAN HOLDER ADDRESS (Include ZIP Code) h. TELEPHONE NUMBER (Include Area Code) 

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

e. NAME AND ADDRESS OF INSTITUTION WHERE PAYMENT IS TO BE SENT (Include ZIP Code) (1) NAME (Last, First, Middle Initial)

(2) SIGNATURE (3) DATE SIGNED (YYYYMMDD)



## DD FORM 2475, 20101005 DRAFT PREVIOUS EDITION IS OBSOLETE. e. E-MAIL ADDRESS f. TOTAL OF PRIOR PAYMENTS

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

g. TYPE OF LOAN (See Instructions) b. ORIGINAL DATE OF PROMISSORY NOTE (YYYYMMDD) c. ORIGINAL LOAN AMOUNT

h. IS THIS A CON- SOLIDATED LOAN? e. LOAN ACCOUNT NUMBER a. FORWARD COMPLETED FORM TO THIS ADDRESS (Include ZIP Code)



### 5. REMARKS (Continue on back if necessary) YES 

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

I certify that this servicemember has performed satisfactorily.

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 b. NO
f. FEDERAL TAX IDENTIFICATION NO. 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.

d. ORIGINAL LOAN AMOUNT

Adobe Designer 8.0 i. LOAN INTEREST j. LOAN FEES 

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## DD FORM 2475 (BACK), 20101005 DRAFT 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. Selfexplanatory. 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 b.

SECTION 5. REMARKS. Use this section to enter additional information that will assist in processing this application. 5. REMARKS (Continued)



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