Loan Data Verification Form printable pdf download

Mississippi Office of Student Financial Aid

Applicant=s Instructions:

Read the Instructions of the form and complete all of Section A.

Mississippi Teacher Loan Repayment Program

DO NOT SEND THIS FORM TO YOUR LENDER. Mail to the

Mississippi Office of Student Financial Aid, 3825 Ridgewood

Loan Data Verification

Road, Jackson, MS 39211-6453.

SECTION A

Completed by the applicant.

(Please type or print.)

3a. Name and address of lending institution/holder of the loan

(i.e., bank, educational institution, loan servicing company)

_ ___________________________________________________________

1. Applicant=s Printed Name (Last, first, middle)

__________________________________

2. Social Security Number

3b. Loan Account Number: ________________________________________

4a. Original Amount of Loan

4b. Date of Loan

5. Current Balance

(if available)

Principal

____________________ as of (date) _________________

6. Current Loan Status (check one)

6a. Deferment

6b. In repayment

7. Are your payments up to date?

8. Monthly Payment Amount

9. Interest Rate of Loan

____%

(if available)

Yes

10. Purpose of the loan (undergraduate loans or graduate loans)

11. Name of Federal or State program under which loan was received (List if

available, i.e., Guaranteed Student Loan, Stafford Loan)

12. Certification by Applicant/Borrower

I hereby apply to enter into an agreement with the State of Mississippi for repayment of the educational loan listed above, incurred solely for the costs of education,

including reasonable living expenses. I hereby certify that the information given in this application is true, complete, and accurate to the best of my knowledge and does

not omit any material fact which would render the statement false, fictitious, or fraudulent as a result of the omission. I am aware that any false, fraudulent, or fictitious

statement may, in addition to other remedies available to the Government, subject me to civil penalties under the Program Fraud Civil Remedies Act of 1986.

I hereby authorize the lending institution, servicing agent, and/or institutional program named above to release information about my loan to the administrators of the

Mississippi Office of Student Financial Aid, and to other authorized Government officials. This authorization shall remain in effect during my application and participation

in the Mississippi Office of Student Financial Aid MTLR program and 90 days after completion of MTLR program contracted service.

_ __________________________________________________________________________

_ ______________________________

Signature of Applicant

Date

Section B B Completed by the lending institution/servicing agent.

Lender/Servicer=s Instructions: Verify the information in Section A, indicating

~Lending Institution/Servicing Agent=s Certification~

any corrections next to the item(s) in question. Complete Section B and return

this form as directed by the cover letter. For questions, call (601) 432-6997.

The undersigned states that, to the best of his or her knowledge, the loan

identified above is a bona fide legally enforceable institutional, State, or