"*" indicates required fields Loan Repayment Assistance Program 2023 NC LEAF Application Special Open Application Period: July 3 - August 11, 2023 Current program participants (Class of 2023) DO NOT need to reapply! Before starting your application, please collect (and scan if necessary) the following documentation: A copy of your Federal Student Aid Summary from the National Student Loan Data System Your loan payment history for the past twelve (12) months showing the amount of your payment(s) and due date(s). Proof of your total loan balance Copy of your most recent Federal 1040/1040A/1040ez tax return. Page 1 Only - showing your AGI. Completed Employer Certification Form Completed Spouse / Domestic Partner Employer Certification Form (if applicable) All files should be saved as PDFs. Applicant's Personal InformationName* First Middle Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyCell Phone*Home PhoneWork Phone*Preferred Email for Application Communications* Work Email* Law School* Graduation Month*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberGraduation Year*20222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Year of Admission*20222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925NC Bar License Number* Create a FOUR digit PIN for your application process* Applicant's Employment InformationEmployer* Office Employer Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State NC Zip Code County*AlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyEmployer's Work Phone*Supervisor's Name* First Last Supervisor's Title* Applicant's Job Title* Is a JD required for your position?*YesNoGross Annual Salary*Date of Hire*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Which counties does your office serve?*Select all the apply.Hold Ctrl and click on a PC or command and click on a Mac to select multiple locations.NC - StatewideNationalAlamanceAlexanderAlleghanyAnsonAsheAveryBeaufortBertieBladenBrunswickBuncombeBurkeCabarrusCaldwellCamdenCarteretCaswellCatawbaChathamCherokeeChowanClayClevelandColumbusCravenCumberlandCurrituckDareDavidsonDavieDuplinDurhamEdgecombeForsythFranklinGastonGatesGrahamGranvilleGreeneGuilfordHalifaxHarnettHaywoodHendersonHertfordHokeHydeIredellJacksonJohnstonJonesLeeLenoirLincolnMaconMadisonMartinMcDowellMecklenburgMitchellMontgomeryMooreNashNew HanoverNorthamptonOnslowOrangePamlicoPasquotankPenderPerquimansPersonPittPolkRandolphRichmondRobesonRockinghamRowanRutherfordSampsonScotlandStanlyStokesSurrySwainTransylvaniaTyrrellUnionVanceWakeWarrenWashingtonWataugaWayneWilkesWilsonYadkinYanceyDo you have a spouse / domestic partner?*YesNo Applicant's Law School Education DebtLaw School Loan #1Name of Lender Original Amount BorrowedCurrent Principal BalanceRequired Monthly Payment**For any loan that is in grace, deferral or forbearance, please indicate date first payment is due and estimated monthly payment.Loan Repayment StatusCurrentForbearance - COVIDForbearance - IBR RecalculationForbearance - ConsolidationOtherIf other, please explain: Next Payment Due DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is this loan consolidated?YesNoIf yes, please describe what loans were consolidated:Were all of the funds included in the principle of this loan borrowed for law school education-related expenses only?YesNoPlease approximate the principal amount attributable to law school here:Do you have another lender to add?*NoYes Applicant's Law School Education DebtLaw School Loan #2Name of Lender Original Amount BorrowedCurrent Principal BalanceMonthly Payment Required**For any loan that is in grace, deferral or forbearance, please indicate date first payment is due and estimated monthly payment.Loan Repayment StatusCurrentForbearance - COVIDForbearance - IBR RecalculationForbearance - ConsolidationOtherIf other, please explain: Next Payment Due DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is this loan consolidated?YesNoIf yes, please describe what loans were consolidated:Were all of the funds included in the principle of this loan borrowed for law school education-related expenses only?YesNoPlease approximate the principal amount attributable to law school here:Do you have another lender to add?*NoYes Applicant's Law School Education DebtLaw School Loan #3Name of Lender Original Amount BorrowedCurrent Principal BalanceMonthly Payment Required**For any loan that is in grace, deferral or forbearance, please indicate date first payment is due and estimated monthly payment.Loan Repayment StatusCurrentForbearance - COVIDForbearance - IBR RecalculationForbearance - ConsolidationOtherIf other, please explain: Next Payment Due DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is this loan consolidated?YesNoIf yes, please describe what loans were consolidated:Were all of the funds included in the principle of this loan borrowed for law school education-related expenses only?YesNoPlease approximate the principal amount attributable to law school here:Do you have another lender to add?*NoYes Applicant's Law School Education DebtLaw School Loan #4Name of Lender Original Amount BorrowedCurrent Principal BalanceMonthly Payment Required**For any loan that is in grace, deferral or forbearance, please indicate date first payment is due and estimated monthly payment.Loan Repayment StatusCurrentForbearance - COVIDForbearance - IBR RecalculationForbearance - ConsolidationOtherIf other, please explain: Next Payment Due DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is this loan consolidated?YesNoIf yes, please describe what loans were consolidated:Were all of the funds included in the principle of this loan borrowed for law school education-related expenses only?YesNoPlease approximate the principal amount attributable to law school here:Do you have another lender to add?*NoYes Applicant's Law School Education DebtLaw School Loan #5Name of Lender Original Amount BorrowedCurrent Principal BalanceMonthly Payment Required**For any loan that is in grace, deferral or forbearance, please indicate date first payment is due and estimated monthly payment.Loan Repayment StatusCurrentForbearance - COVIDForbearance - IBR RecalculationForbearance - ConsolidationOtherIf other, please explain: Next Payment Due DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is this loan consolidated?YesNoIf yes, please describe what loans were consolidated:Were all of the funds included in the principle of this loan borrowed for law school education-related expenses only?YesNoPlease approximate the principal amount attributable to law school here:Do you have another lender to add?*NoYes Applicant's Law School Education DebtAdditional LendersPlease Upload a PDF with information on any additional lenders*Include Name of Lender, Original Amount Borrowed, Current Principle Balance, Required Monthly Payment, Loan Repayment Status, Next Payment Due Date, Information on Consolidation, and Amounts Related to Law School.Accepted file types: pdf, Max. file size: 50 MB. If your law school has an LRAP Program, you are required to apply to such program for assistance.Does your Law School have a loan repayment assistance program?YesNoPlease upload documentation of your application for assistance and the outcome.*Accepted file types: pdf, Max. file size: 50 MB. Application EssayEssay*Compose an essay describing your commitment to public interest law. (limit: 1250 characters max) Additional Required DocumentsA copy of your Federal Student Aid Summary from the National Student Loan Data System Your loan payment history for the past twelve (12) months showing the amount of your payment(s) and due date(s). Proof of your total loan balance Copy of your most recent Federal 1040/1040A/1040ez tax return. Page 1 Only - showing your AGI. Completed Employer Certification Form Completed Spouse / Domestic Partner Employer Certification Form (if applicable)A Copy of you Federal Student Aid Summary from the National Student Loan Data System*Accepted file types: pdf, Max. file size: 50 MB.Your loan payment history for the past twelve (12) months showing the amount of your payment(s) and due date(s)*Accepted file types: pdf, Max. file size: 50 MB.Proof of your total loan balance*Accepted file types: pdf, Max. file size: 50 MB.Copy of your most recent Federal 1040/1040A/1040ez tax return. Page 1 Only - showing your AGI.*Accepted file types: pdf, Max. file size: 50 MB.Completed Employer Certification Form*Accepted file types: pdf, Max. file size: 50 MB.Completed Spouse / Domestic Partner Employer Certification Form*Accepted file types: pdf, Max. file size: 50 MB. Certification*All of the information on this form is true and complete to the best of my knowledge and belief. I understand that if I am selected to participate in this program, I will be required to provide authorizations to enable NC LEAF to periodically verify loan and employment information. By submitting this application, I acknowledge and agree to the NC LEAF Program Guidelines. Finally, I understand that this application is not complete and will not be considered without appropriate employer information and lender verification information, and all attachments required by this application. I have read and agree to the Certifications aboveSubmission Review{all_fields:admin, value}HiddenSubmission Date MM slash DD slash YYYY Printed Name* Signature*
