Indiana John R. Justice Program - 2014-2015

John R. Justice Indiana Student Loan Repayment Program

2014-2015 APPLICATION FORM

Federal Loan Repayment Assistance Program

For Public Defenders and Prosecutors

Under the John R. Justice Prosecutor and Defender Incentive Act

Certification

I understand that an application packet will not be considered complete unless the following documents are submitted.

Page 2 / Employment and Licensure Verification
Page 3 / Loan Information:
· List all eligible loans
· Attach a detailed statement for each loan listed on Page 3. Here is the link to the National Student Loan Data System (NSLDS)
· Complete the “Loan Verification Form” on Page 4
Page 5 / Applicant Certification and Signature
Submit / Financial Information: You must submit a copy of the most recent Federal Form 1040 you have filed (unless your most current 1040 is already on file). Your financial information will be kept confidential.
Submit / Service Agreement: Complete and sign the John R. Justice Student Loan Repayment Program JRJSLRP Service Agreement. The Service Agreement is also posted online at https://www.bja.gov/Funding/JRJ_Service_Agreement.pdf
Submit / Cover Letter: Submit a cover letter highlighting public service and a commitment to continued public service for three years.
Submit / Transcripts: Unofficial Law School transcript.
Submit / Resume: Submit a copy of your current resume including your employment and education history as well as any notable professional affiliations or achievements.

Complete, sign, date and return by Monday, March 2, 2015. You may fax it to Natalie Robinson at 317-232-7979 or via email

EMPLOYMENT VERIFICATION

Employment Information
Last Name / First Name / Middle Initial
Employer / Employer Address
Job Title / Date of Hire
Current Annual Salary / Applicant Employed Full Time? (minimum of 30 hrs/week)
Yes No
Work Address / Work County
Work Phone / Work Email Address
Certification/Signature
The above named employee has applied for benefits from the Indiana John R. Justice Grant Program. I have verified my employee’s information is true and accurate.
Employer’s Printed Name / Employer’s Title
Employer’s Signature / Date

LICENSURE INFORMATION

Applicant Information
Last Name / First Name / Middle Initial
In which state(s) are you licensed to practice law?
In what state are you currently practicing? / Bar Number
Law Degree Received From / Year of Degree

Indiana John R. Justice Program - 2014-2015

LOAN INFORMATION

Please list all eligible loans in the table below. The following loans are eligible for repayment with JRJ funds:

1. A loan made, insured, or guaranteed under part B of subchapter IV of chapter 28 of Title 20 (Federal Family Education Loan Program);

2. A loan made under part C or D of subchapter IV of chapter 28 of Title 20 (William D. Ford Federal Direct Loan and Federal Perkins Loans);

3. A loan made under section 1078-3 or 1087e(g) of Title 20 (Federal consolidation loans and Federal Direct Consolidation loans, respectively).

The first listed loan will be the one that your benefits are paid to. If funds awarded are sufficient to completely pay the balance due on that loan, the excess of the award will be paid to the second loan listed. You are required to disclose whether any of the loans listed below are financed through other educational loan repayment or forgiveness programs and/or grants.

Lender-Servicer
Name/Address/Account Number/Loan Type / Original Loan Amount / Outstanding Balance / Monthly Payment / Amount Paid Against Loan / Other Sources(s) of Loan Assistance /
Totals / $0.00 / $0.00 / $0.00 / $0.00
Total Adjusted Gross Income / (as stated on most recent 1040 filed)

Indiana John R. Justice Program - 2014-2015

LOAN VERIFICATION RELEASE FORM

The applicant must provide a detailed statement for each eligible educational loan that contains the information in the bulleted listed below.

Required Loan Information:

· Name and Address of Lender

· Account Number

· Type of Loan (Federal Direct, etc)

· Outstanding Balance

· Type of Repayment Plan

· Loan Status (current, deferral, etc)

You may provide a copy of your NSLDS statement. However, be sure to open the detail information for each loan from the NSLDS Summary Page so that the loan details with the information outlined above is displayed. Please print and attach a copy of the detail statement for each loan. If the statement does not contain all the required information, the applicant should write in the rest of the information. Incomplete statements will not be accepted.

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Complete the release below to give permission to the Indiana John R. Justice Program to obtain additional information, if needed.

I authorize my lenders, specified on Page 3, to provide the loan information requested by the Indiana John R. Justice Program.

Applicant Signature / Date

APPLICANT CERTIFICATION and SIGNATURE

All the information on this application is true and complete to the best of my knowledge. If asked by the Indiana John R. Justice Program, I will provide proof of the information I have given on this application.
Signature of Applicant / Date

I understand that the full application packet must be received by Monday, March 2, 2015. Please mail to:

Office of the Indiana Attorney General

Attention: Natalie Robinson

Government Center South, 5th floor

302 W. Washington Street

Indianapolis, IN 46204