Loan Forgiveness Application Form
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Loan Forgiveness Application
NCSEAA Loan Forgiveness Programs
SECTION 1. Borrower Request for Loan Forgiveness
Name: ______________________________________________
NCSEAA PID#: ________________
Address: _____________________________________________
Phone#: (____) _________________
(PO Box, Street)
__________________ ______
___________
Email: ________________________
City
State
Zip Code
Loan Program Name:______________________________________________________________________
(Name of loan you received from the NCSEAA.)
Employer Name:_________________________________________________________________________
Employer Address: _____________________________________________________________________
Full-time Half-time Part-time
Position Title: ____________________________________
I request my obligation to the State of North Carolina be repaid through loan forgiveness. I authorize my
employer to provide information to the NCSEAA about the dates of my employment, the position I hold, and
my full-time/part-time status as needed to qualify for loan forgiveness of my NCSEAA loan.
_____________________________________________________
______/______/______
Signature of Borrower
Date (MM/DD/YYYY)
SECTION 2. Certification of Employment (To be completed by human Resources or an authorized official)
Type: Full-time Half-time Part-time
Start date of Employment: ______/______/______
Date (MM/DD/YYYY)
Type: Full-time Half-time Part-time
End date of Employment: ______/______/______
(If applicable)
Date (MM/DD/YYYY)
Was there any unpaid leave of absence during this period? No Yes*
*If yes, please attach explanation and include dates of absence(s).
Employee’s Position Title: ________________________________________________________________
If an Educator: Subject taught:_____________________________________________________________
If a Nurse: LPN RN FNP CRNA Nurse Educator Other __________________
I attest the foregoing information is true and correct to the best of my knowledge.
________________________________________
______/______/______
Signature of Official
Date (MM/DD/YYYY)
_______________________________________________________________________________________________
Name and Title (Please type or print)
_____________________________________________________
____________________________
Name of Employing Agency
Telephone Number
____________________________________
________________________
_______
__________
Mailing Address (PO Box, Street)
City
State
Zip Code
Please direct questions to Repayment Services at (919) 549-8614, ext 4654 or (800) 700-1775, ext 4654.
RETURN THIS FORM TO:
SEAA, P O Box 14223, Research Triangle Park, NC 27709-4223
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