NASA Headquarters' Directives
HQPR 3000.1 Effective Date: May 24, 2016 Expiration Date: May 24, 2021 Responsible Office: LE	Student Loan Repayment Program Plan

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Employee Name: ____________________________________

Position (Title, Series and Grade): ________________________________

Appointment Type: _________________________

Effective Date: __________________

1. The National Aeronautics and Space Administration (NASA) agrees to repay an annual amount of _____________per year (no more than $10,000) and a total amount of $__________________ (no more than the lesser of $60,000 or the employee's loan balance). As of ________________, I owe $ ________________ towards my student loan.

My monthly loan repayment is $________________.

My student loan is ___________________________________________________. (specify: A loan made or insured under parts B, D or E of Title IV of the Higher Education Act such as: Stafford Loan, Supplemental Loan, Plus Loan, Federal Consolidation Loan, Defense Loan [made before July 1, 1972)], National Direct Student Loan [made between 7-1-72 and 7-1-87], Perkins Loan; A health education assistance loan made or insured under part A of title VII of the Public Health Service Act, or under part E of Title VIII of that Act such as: Nursing Student Loan Program Loan, Health Profession Student Loan Program Loan, or Health Education Assistance Loan).

My lending institution is ________________________________________________.

The lending institution's mailing address is ______________________________________________

______________________________________________

______________________________________________

______________________________________________

Telephone number of lending institution________________________________

My loan account number is ___________________________.

2. In return for this student loan repayment, I agree to continue in the employment of NASA for a minimum period of 3 years. Periods of leave without pay may serve to extend my service agreement up to but not exceeding the period of the leave without pay.

3. I understand that my minimum 3-year service agreement will commence on the date that NASA makes the first student loan repayment in my behalf. Any loan repayments beyond three years will serve to extend my service agreement for an additional year after the last loan repayment has been made.

4. I further understand that NASA's commitment to repay my loan is for one year, subject to yearly extensions by NASA. I understand that NASA has the discretion to determine the repayment benefit amount each year. A new service agreement is not needed for annual extensions or renewals.

5. I understand that this service agreement in no way constitutes a right, promise, or entitlement for continued employment or noncompetitive conversion to the competitive service.

6. I agree to maintain an acceptable level of performance.

7. I understand that I am required to pay Federal income and employment taxes and appropriate state and local taxes on all loan repayments that NASA makes in my behalf notwithstanding the Agency's repayment of the loan directly to the lender. Federal tax withholdings, including social security and Medicare, will be deducted or applied at the time any loan repayment is made. I understand that NASA is responsible for reporting the loan payments and the Federal taxes associated with the Student Loan Program to the Internal Revenue Service.

8. I understand that NASA is not responsible for any late fees that may be assessed by the holder of the loan.

9. I certify that I have never defaulted on any student loans.

10. I understand that I am responsible for making loan payments on the portion of my loan(s) for which NASA is not making payments.

11. I agree to reimburse NASA for any and all loan repayments that NASA makes in my behalf if I fail to complete the terms of my service agreement. I understand that I will also be required to reimburse NASA for any and all loan repayments if I am separated from the Agency either involuntarily on account of misconduct or voluntarily. I further understand that this means that I am required to reimburse NASA if I transfer to another Federal Agency.

12. I understand that NASA has the right to terminate this agreement at any time, for any reason.

CERTIFICATION

My statements on this form and any attachments are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that a knowing and willful false statement on this from shall be punishable by fine or imprisonment, or both. (18 U.S.C. §1001) In addition to any other remedy or sanction provided for under law or regulation, any person who falsely certifies this document shall be subject to a civil penalty under the Program Fraud Civil Remedies Act of 1986 (31 U.S.C. 3801-3812), as implemented by NASA regulations set forth at 14 C.F.R. Part 1264.

PRIVACY ACT STATEMENT

Pursuant to the Privacy Act of 1974, 5 U.S.C. §552a, the following statement is furnished to individuals supplying information for participation in the NASA Student Loan Repayment Program.

AUTHORITY: 5 U.S.C. §5379

PURPOSES AND ROUTINE USES: The principal purpose for collecting this information is to determine an employee's eligibility for participation in the NASA Student Loan Repayment Program. This information may be disclosed to NASA contractors for payroll and personnel processing, to lending institutions for verifying student loan balances, to the Internal Revenue Service for reporting of Federal tax obligations, to the Office of Personnel Management for annual reporting requirements, and standard routine uses 1-4 inclusive as set forth in Appendix B of NASA's Annual Notice and Amendments to Systems of Records.

EFFECT OF NONDISCLOSURE: Supplying the information is voluntary on your part. However, failure to supply the requested information may result in your ineligibility for participation in the NASA Student Loan Repayment Program.

RELEASE AUTHORIZATION

By my signature below, I hereby authorize NASA to obtain my student loan information, referred to in Item 1 above, from my lending institution, or its assignees.

This release is executed by me with my full knowledge and approval that NASA or such other agency of the Government of the United States as is authorized by NASA may use, consider, and disclose such information, statements, and records within the scope of its official duties and responsibilities.

__________________________________________
(Typed name of Employee)

___________________________________________
(Signature of Employee)

___________________________________________ (Date)

___________________________________________________
(Typed Name and Title of NASA Authorizing Official)

___________________________________________
(Authorizing Signature)

___________________________________________ (Date)