Ut Law Loan Repayment Assistance Program Application Form Page 4

EMPLOYMENT AND SALARY INFORMATION

Graduate

Employer

Address (number and street)

Address (city, state, zip)

Phone number

Name of supervisor

Employment starting date and

ending date (if applicable)

Are you employed at least 35 hours per

week?

Annual salary, commissions and fees

Do you expect your position to continue for

at least six months from now?

Brief job description

CERTIFICATIONS

I certify that my net assets do not exceed $25,000 excluding my primary place of residence, my

retirement accounts, and one half of my spouse’s assets accumulated after our marriage

(excluding my spouse’s retirement accounts).

I also certify that all of the information provided on this form is true and complete to the best of

my knowledge. I agree to provide proof of the information I have given on this form if requested

by UT Law.

Applicant’s signature: __________________________________ Date: ____________________

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