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HQPR 3000.1
Effective Date: May 24, 2016
Expiration Date: May 24, 2021
Responsible Office: LM4
Student Loan Repayment Program Plan
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Table of Contents | Preface | Chapter1 | Chapter2 | Chapter3 | Chapter4 | Chapter5 | Chapter6 | Chapter7 | Chapter8 | Chapter9 | AppendixA | AppendixB | AppendixC | AppendixD

APPENDIX D

REQUEST FOR STUDENT LOAN REPAYMENT BENEFIT UNDER THE

STUDENT LOAN REPAYMENT PROGRAM

5 U.S.C. 5379

Employee Name:

Social Security Number:

Title Series/Grade/Step Type of Appointment:

Total Amount of Student Loan Repayment Benefit Received to Date (include the requested amount from this
request form): $__________________

Student Loan Repayment Benefit Amount Requested: $_______________

Student Loan Repayment Benefit for Year Number: (Circle One)

1 2 3 4 5 6 Other ____
NOTE: Attach service agreement to this request form.

Current Balance of Outstanding Loan: $_________________
NOTE: attach official documentation from loan holder documenting loan balance, loan account
number and type of loan to this request form.

Compensation:

Salary Base/Locality Pay $ _______________

Other Continuing Pay, e.g., PSP, retention allowance, etc. $ _______________

Other Payments, e.g., lump sum payments $ _______________

Student Loan Repayment Benefit Amount $ _______________

TOTAL COMPENSATION $ _______________

_____________________________________
Recommending Official Name/ Title

__________________________
Date

_____________________________________

Certification of Funds Official Name/Title

____________________________
Date

_____________________________________
Personnel Official Title

_______________________________
Date

____________________________________
Approving Official Title

_________________________________
Date

____________________________________
Effective Date

_______________________________________
Expiration Date


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