LOAN REPAYMENT ASSISTANCE PROGRAM (LRAP) $form_text ONLINE APPLICATION FOR CANCELLATION OF LRAP LOANS Lived Name (First, Middle, Last, Suffix) (required) Student ID Number (required) (do NOT enter your Social Security Number) Graduating Class (YYYY) Email Address (required) * Email is our primary method of contacting you. Please provide an email which you will check regularly and notify us of any changes. My current and permanent addresses have not changed. Complete the following fields only if your address has changed: Preferred Mailing Address Select One Current Address Permanent Address Please select your preferred mailing address. Current Address Line 1 Current Address Line 2 Current City Current State Current Zip Code Permanent Address Line 1 Permanent Address Line 2 Permanent City Permanent State Permanent Zip Code My marital and dependent status has not changed Complete the following fields only if your status has changed: Marital Status Select One Single Married Divorced/Widowed If married, spouse's name Number of Dependent Children as defined by the federal tax code Ages of Dependent Children Briefly list any changes in your loan portfolio such as consolidation, paid off loans, or other notes. characters left My salary/income has not changed Complete the following fields only if your salary has changed: Date of Salary Change Previous Salary New Salary My employment/position has not changed Complete the following fields only if your employment has changed: Date of employment change Previous Salary Start Date at Previous Salary End Date at Previous Salary New Salary Start Date at New Salary End Date at New Salary REQUIRED: Please report actual gross income for the length of your contract. Your contract start and end dates are shown on your award letter. (If you are married, your spouse's income must also be reported.) Applicant Wages and Salaries Other Income (please specify) Total Income Spouse Wages and Salaries Other Income (please specify) Total Income REQUIRED: Attach a copy of the Employer Verification Form (see our Forms Page) completed and signed by your employer verifying your income. Employer Verification Form REQUIRED: Attach proof of payment for all of your loans in the form of payment history or statements of payments. You can find a payment history on your loan servicer's website. Please submit proof of payments covering all months of your LRAP contract. If you are not able to locate a payment history online covering all months of your LRAP contract, you should contact your loan servicer(s) and request that a complete payment history (or "statement of account") be mailed to you, or submit a redacted bank statement. Proof of Payment Document Proof of Payment Document Proof of Payment Document Proof of Payment Document Proof of Payment Document Proof of Payment Document By typing my name below, I certify that all of the information provided on this form is true and complete to the best of my knowledge. I agree to provide verification of the information that I have supplied on this form if requested by the School of Law or the program administrators. Please type your full name (required)