ࡱ> y bjbj {{ *****>>>8v*>V|j@UUUUUUU$X[tU*U**4}V4| | | F**U| U| | KOr3jvM&UV<VMB!\Z!\LOO@!\*P| UUnV!\ :  Oklahoma District Attorneys Council John R. Justice Loan Repayment Program 2011-2012 REQUEST FOR RENEWAL Submit Application postmarked no later than April 11h 2012 District Attorneys Council JRJ Loan Repayment Program Attn: Lee Cohlmia 421 NW 13th Street Suite 290 Oklahoma City, Ok 73103 RECIPIENT INFORMATION Last Name:  FORMTEXT      First Name: FORMTEXT      M.I. FORMTEXT       CONTINUED ELIGIBILITY CERTIFICATION I declare under penalty of perjury that the information I provided on my grant application (e.g. loan amount, lender, loan status) remains current. In particular, I certify:  FORMCHECKBOX  I have no student loans in default status.  FORMCHECKBOX  I understand I may be subject to a random audit to verify loan information and status.  FORMCHECKBOX  I remain employed with the same employer OR  FORMCHECKBOX  I have changed jobs, but remain in continual eligible employment in Oklahoma. (As indicated below, all renewal applicants are required to provide an updated Employer Verification form).  FORMCHECKBOX  I remain a Member in Good Standing with the Oklahoma Bar Association. Applicants Signature Date FORMS NEEDED FOR JRJ GRANT AWARD RENEWAL I understand that an application packet will not be considered complete unless the original and five copies of the following documents are submitted: Application: Complete and sign the 2011-2012 Request for Renewal of JRJ Loan Repayment Incentive form. Proof of Employment: Complete the top portion of the Employment Verification form and have your employer complete the lower portion of the Loan Verification form. Proof of Loans: Submit an NSLDS ( HYPERLINK "http://www.NSLDS.ed.gov" www.NSLDS.ed.gov) statement as well as a Loan Verification Release Form for each lender/servicer who administers or holds any of your student loans. The NSLDS statement must contain all of the required loan information as outlined on the Loan Verification Release Form. NOTE: If applicant has never utilized NSLDS, applicant will have to first acquire a PIN number from the system. The activation of new PIN numbers can take a couple of days.  HYPERLINK "http://ok.gov/dac/John_R_Justice_%28JRJ%29_Student_Loan_Repayment_Program.html" \l "verify" See instructions on how to obtain an NSLDS statement. Federal Form W-9: Complete and sign the Federal Form W-9. NOTE: Applicants only need to complete name and address as individual/sole proprietor, include social security number in Part I and sign in Part II. Please submit only page one of the form (the remaining three pages are additional instructions for the applicant only). Vendor Form: If applicant is not currently employed by the State of Oklahoma, complete and sign a Vendor/Payee Form. And one copy of the following: Proof of Financial Information: Submit copies of most recent federal and state tax returns for applicant and domestic partner. Include schedules but no worksheets. Financial information will be kept confidential. Please verify current contract information: Home Address: FORMTEXT      Home Phone: FORMTEXT      Work Phone: FORMTEXT      Email: FORMTEXT       I understand that the full application packet must be postmarked by April 11, 2012. All the information on this application is true and complete to the best of my knowledge. If asked by the Oklahoma District Attorneys Council for the JRJ Grant Program, I will provide proof of the information I have given in this application. Applicants Signature Date Oklahoma JRJ Loan Repayment Program 2011 2012 Employment Verification Section A - Release (to be completed by applicant) Last Name: FORMTEXT      First Name: FORMTEXT      MI: FORMTEXT      Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT   Zip Code: FORMTEXT       I authorize my employer to provide the employment information requested by the Oklahoma JRJ Loan Repayment Program. _________________________________________________ _____________________________ Applicant's Signature Date ******************************************************************************************************************** Section B - Employment (to be completed by employer) The above named employee has applied for benefits from Oklahoma JRJ Loan Repayment Program. Please complete the following section and return this form to the applicant. Job Title of Employee: ______________________________________ Date of Hire: ______________________________________________ Is the applicant employed full-time (not less than 75 percent of a 40 hour work week?) ___Yes ___No Name of Organization: _______________________________________ Employees assigned workstation (city/county): ______________________________ Current Annual Salary: ______________________________________ The employment noted above satisfies which of the following requirements (check one): Employee prosecutes criminal or juvenile delinquency cases for the state, a local government agency, or tribal government. Employee is employed by a state or local unit of government (including tribal government) that prosecutes criminal or juvenile delinquency cases and provides supervision, education, or training of other persons prosecuting such cases. Employee legally represents, or supervises, educates or trains others who legally represent indigent persons in criminal or juvenile delinquency cases. Employee legally represents, or supervises, educates or trains others who legally represent indigent persons in criminal or juvenile delinquency cases for a non-profit organization operating under a contract with the state or unit of local government providing such representation. Employee is a full-time federal defender attorney in a defender organization pursuant to Subsection (g) of Section 3006A of Title 18, U.S. Code, which provides legal representation to indigent persons in criminal or juvenile delinquency cases. Do you believe applicant is committed to staying employed there for a minimum of three years? ___Yes ___No If employer is a state agency, does Authorized Official understand the agency may have tax obligations if applicant receives JRJ funding? ___Yes ___No For questions concerning employer tax implications, please contact Lee Cohlmia or Bud Webster at the Oklahoma District Attorneys Council (405-264-5000). I certify that the information provided above is true and complete to the best of my knowledge and that the applicant meets the JRJ Program eligibility definition of prosecutor or public defender. _____________________________________ _____________________________________ Signature of Authorized Official Date Printed name: _________________________ Title: _________________________________ Telephone number: _____________________ E-mail: ______________________________ Oklahoma JRJ Loan Repayment Program 2011 2012 Loan Verification and Release Form The applicant must submit a NSLDS statement for each eligible educational loan that contains the information listed below. If the statement does not contain all of the required information, the applicant should write in the rest of the information. Incomplete statements will not be accepted. A. 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Make copies of the form if needed for multiple lenders. 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