|NASA Headquarters' Directives|
Effective Date: May 24, 2016
Expiration Date: May 24, 2021
Responsible Office: LM4
|Student Loan Repayment Program Plan|
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Check the NASA Online Directives Information System (NODIS) Library
to verify that this is the correct version before use.
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.
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
Certification of Funds Official Name/Title
Personnel Official Title
Approving Official Title