Name(Required) First Middle Last NC LEAF ID Number(Required) Your NC LEAF ID Number is your NC Bar License Number with your 4 number PIN at the end (e.g. 12345-1234). If you need your PIN resent, please email us.Please select your Program(Required)NC LEAF RecipientLegal Aid of NC EMPLOYEEEmail Address(Required) Enter Email Confirm Email A.(Required)ALL PAPERWORK MUST BE COMPLETED TO RECEIVE REIMBURSEMENTS. Recipient Data Form – This form must be completed online. It is your duty to keep NC LEAF apprised of any changes to your information. ACH Form (Direct Debit) – Please complete this form online. Reimbursements will be made by ACH for direct deposit into your account. Please confirm your banks routing number to ensure successful payments. Online Ledger – This is where you will keep track of all loan payments made. You will not be reimbursed if your ledger is not complete. This must be completed quarterly. Contract – This contract must be signed and dated. I understand and agree.B.(Required)RECIPIENTS WILL BE REIMBURSED ON A QUARTERLY BASIS ONCE PROOF OF PAYMENT FOR THE QUARTER HAS BEEN SUBMITTED. QUARTERLY REIMBURSEMENT WILL BE PROCESSED IN APRIL, JULY, OCTOBER & JANUARY. I understand and agree.C.(Required)REIMBURSEMENTS WILL BE BASED ON THE AMOUNTS PAID (NOT TO EXCEED AMOUNT DUE) AND REPORTED FOR EACH QUARTER. I understand and agree.D.(Required)PAYMENT VERIFICATIONS MUST BE SUBMITTED WITH YOUR PAYMENT FORM. Verification of the previous three months of repayment must be provided to NC LEAF by the 7th day of the next quarter following disbursement (April 7, July 7, October 7 & January 7). Failure to provide timely payment verification will result in delayed reimbursement and may lead to termination of loan repayment assistance. Recipients must notify NC LEAF immediately of any employment changes, address changes or name changes. I understand and agree.E.(Required)REIMBURSEMENT GUIDELINES You will be reimbursed up to the maximum of $400* per month for required loan payments you make in 2023 pursuant to you providing proper documentation. NC LEAF does not reimburse for any payments that you make that are not required nor above the required amount. I understand and agree.F.(Required)TESTIMONIALS. When asked, I agree to provide a testimonial about my participation in the NC LEAF program that NC LEAF may use for grant applications, grant reporting, the NC LEAF website, and any other NC LEAF materials as needed. When I am asked to create this testimonial, I will have the choice to make it anonymous or not. I understand and agree.G.(Required)SHARING CONTACT INFORMATION. If needed, I agree to have my name, job title, county where I work, and email shared with a lobbyist or fundraiser working to secure state funding for NC LEAF. The lobbyist may contact you for testimonials or to ask you to advocate on behalf of the program. YES - My contact information can be shared. NO - Please do not share my contact information. Signature(Required)HiddenDate MM slash DD slash YYYY
