Names and birthdates of dependent children under the age of 24:

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1 Page 1 NOTRE DAME LAW SCHOOL LOAN REPAYMENT ASSISTANCE PROGRAM APPLICATION FORM Deadline: November 1 Your application must be submitted in hard copy form and arrive to the Law School by November 1 st. Faxed or scanned copies are not acceptable substitutes. The Law School strictly enforces the November 1 st deadline. Your application is not complete and will not be evaluated until you have submitted all required information. If some compelling reason prevents you from fully completing your application or from submitting any required documentation, please provide an explanation. Without a valid explanation, an incomplete application will not be considered received. The Program Coordinator will confirm the arrival, but not the completeness, of your application via within two business days after delivery. If you do not receive an confirmation within that period, please contact Cathy Kustner immediately at (574) or [email protected] to verify that your application has arrived. A. Applicant Information: Applicant s Name: Law School Graduation Month: Year: Social Security #: Mailing Address: Cellphone or Home Telephone: ( ) Work Telephone: ( ) Primary Address: Secondary Address: Marital Status: Spouse=s Name (if applicable): Names and birthdates of dependent children under the age of 24: For administration use only: Date received Date confirmed Date 1 st check requested LRAP AMOUNT $ Date 2nd check requested LRAP AMOUNT $ (05-15)

2 Page 2 B. Applicant Employment Information: Name of Employer: Position/Job Title: Starting Date of Employment: Employer s Address: Work Address (if not on page 1): Job Responsibilities: Hours Per Week: Contact Person: Contact Person Telephone: ( ) C. Employment Information for Spouse Name of Employer: Employer s Address: Position/Job Title: Time (number of years) in Position:

3 Page 3 INCOME INFORMATION WORKSHEET Applicant s Name Spouse s Name (if applicable) Please report your current income and current pre-tax withholdings and your estimated other income for the following calendar year. Note: Federal, state and local taxes do not need to be identified below. If you are married, you must also report your spouse=s estimated income. Applicant Spouse*** Current Annual Salary* (attach most recent pay stub) Less: Annual pre-tax withholding for health insurance Less: Annual pre-tax withholding for retirement savings** Less: Annual pre-tax withholding for Less: Annual pre-tax withholding for Overtime / Bonus / Commissions (estimate for next year) Total Interest Income (estimate for next year) Total Dividend Income (estimate for next year) Business Income (estimate for next year) Alimony / Child Support Received (estimate for next year) Unemployment Compensation (estimate for next year) Rental Income (estimate for next year) Trust Fund Income (estimate for next year) Other Income Specify: TOTALS (net of pre-tax withholdings)

4 Page 4 A copy of your most recent employer paystub is required for salary verification purposes. If you have not yet started in your qualified position, an offer letter with your annual salary must be included in your application unless you are applying for conditional acceptance. LRAP benefits cannot be distributed without a current paystub. To take advantage of any income adjustments, this paystub must include current pre-tax withholdings for items such as the employee portion of health insurance premiums, employee contributions to a qualified retirement program or any other eligible pre-tax withholding. If these benefits have not yet started as a result of a recent hire, please send in a current paystub for income verification purposes and then follow this up with a current paystub when your pre-tax withholdings have been activated. *If you expect your annual salary to change between the application date and the 1 st quarter of the following year, please explain your anticipated changes: **The LRAP limits retirement contribution deductions to 10% of annual salary. This deduction must be supported by actual withholding on your current pay stub. ***If your spouse is employed, a current paystub is also required. If your spouse is selfemployed, please provide some type of salary verification or explanation of how you determined your spouse s annual salary. Loan Repayment Assistance List any loan repayment assistance that you or your spouse are currently receiving, have applied for, or otherwise expect to receive (include recipient, amount, source, and dates of any assistance):

5 Page 5 LOAN INDEBTEDNESS WORKSHEET Applicant s / Borrower s Name: You must include documentation with your application. SEE PAGE 9 OF THIS APPLICATION. You must complete this worksheet in its entirety and the documentation must support what is reported. If you are married, your spouse must also submit a separate copy of this loan indebtedness worksheet. Notre Dame Law School Loans (e.g., Federal Subsidized and Unsubsidized, Perkins, Grad Plus, CitiAssist, Law Access and other private loans borrowed through ND Financial Aid Office) Type of Loan Period Due Name of (Fed Sub, Unsub, Current Loan (month and year Lender or Grad Plus, Original Amount Balance (as of Monthly payments begin Loan Perkins, Private) of Loan application date) Payments and end) Servicer A. First Year at NDLS B. Second Year at NDLS C. Third Year at NDLS Total NDLS Loans NOTE: For loans that have been consolidated, report the original loan amount in the appropriate section (i.e., 1L, 2L, 3L, undergrad) and then report the rest of the loan information (current balance, monthly payment, period and lender) in only ONE line with appropriate notation identifying which loans have been consolidated. If your federal loans are being repaid under the Income-Based Repayment Plan, please identify as such and report the month in which payments are subject to change.

6 Page 6 LOAN INDEBTEDNESS WORKSHEET (continued) Applicant s / Borrower s Name: Non-NDLS Education Loans (including undergraduate and Bar Loans) Type of Loan Period Due Name of (Fed Sub, Unsub, Current Loan (month and year Lender or Grad Plus, Original Amount Balance (as of Monthly payments begin Loan Perkins, Private) of Loan application date) Payments and end) Servicer A. Undergrad Loans B. Bar Loans C.1 st year at other law school (if applicable) or other educational loans not included above Total Non-NDLS Are any of your loans in forbearance? Yes No. If so, which loans, and when does the forbearance end? NOTE: If applicable, report your spouse s educational loans on a separate worksheet using the same format found on page 5 and 6. Make sure these duplicative pages are clearly marked as SPOUSE.

7 Page 7 ASSET WORKSHEET Applicant s Name Spouse s Name Please report your assets as of the September 30 before the date of your application. If you are married, you must also report your spouse=s assets on that date. BALANCES AS OF SEPTEMBER 30 In Applicant s Name In Spouse s Name Jointly Owned Cash and Checking Accounts Savings/Money Market Accounts Investments (excluding retirement accts) Home Equity* (excluding 1 st $50,000) Trusts Other Assets* (please list and provide or attach additional information) TOTALS *Do not include primary home equity under $50,000, retirement accounts, automobiles or household goods.

8 Page 8 POWER OF ATTORNEY State of County of I,, appoint the Administrator of the Loan Repayment Assistance Program of the Notre Dame Law School (the AProgram@) as my attorney-in-fact, in my name and on my behalf, to access any and all information related to my student loans, including but not limited to repayment information, and to sign promissory notes and any other agreements pertaining to my participation in the Program. This the day of, 20. (Name) State of County of Sworn to and subscribed to before me on the day of 20. My Commission Expires: Notarial Seal Notary Public

9 Page 9 REMEMBER, YOUR APPLICATION IS NOT COMPLETE AND WILL NOT BE EVALUATED UNTIL YOU HAVE SUBMITTED ALL REQUIRED INFORMATION. IN ADDITION TO THE COMPLETING THE INCOME, LOAN INDEBTEDNESS, AND ASSET WORKSHEETS FOUND IN THIS APPLICATION, PLEASE ATTACH THE FOLLOWING REQUIRED DOCUMENTS: Resume with biographical information and employment information Copy of your most recent paystub or offer of employment (with expected salary) Loan documentation for ALL DEBT listed on the loan indebtedness worksheet(s). This lender documentation must include, at a minimum, the following: the original amount borrowed and the date of disbursement for each loan your current loan balance(s) monthly payment amount for each outstanding loan the period for which your loan(s) will be repaid month and year payments begin for each loan Often, it will be necessary to provide multiple lender reports to document all the required data. If you have CONSOLIDATED YOUR DEBT, provide all the necessary lender documentation to trace the loan origination. If you have consolidated law school loans with undergraduate debt, your documentation must be sufficient to determine an appropriate proration of this consolidated debt between law school and other educational loans. Please clearly mark all lender documentation as 1L, 2L or 3L loans and Undergraduate loans to associate your documentation to all loans reported on the loan indebtedness worksheet. If you are married and your spouse has any educational debt, please complete a SEPARATE indebtedness worksheet and provide all the same documentation to take advantage of this income adjustment applied against your spouse s income. Copy of the most recent Federal income tax return(s) for you and your spouse (even if you were a full-time student during that year). If you or your spouse did not file a Federal income tax return for that year, please attach a statement certifying that fact. If you received benefits under this Program last year and you have already satisfied this requirement, you do not need to send another copy. Power of Attorney form (attached) which MUST be notarized Personal statement (optional) It is strongly advised that you retain a complete copy of your submitted application to be able to answer follow-up questions that may arise during the year.

10 Page 10 CERTIFICATION AND AGREEMENT I certify that all information provided above is true and accurate as of this date. I understand that the deadlines to apply for the Loan Repayment Assistance Program at the Notre Dame Law School (the AProgram@) in future years will be November 1. I further understand that this Program is operating on limited and nonguaranteed funding; that the total amount available under the Program will be determined annually by the Dean; that the Law School need not award the entire amount available in any given year; that the Law School may establish a cap on the amount of benefits that will be awarded to any graduate during the year; and that there is no guarantee that graduates selected for the Program one year will be selected in future years. I agree to use any loans obtained from the Notre Dame Law School under this Program only to satisfy obligations arising from eligible loans. I further agree to provide any additional or clarifying information or documentation that the Program Administrator or Program Coordinator may request and to notify the Program Coordinator within two weeks of any significant changes in my/our circumstances, such as a change in employment status, a change in loan repayment terms or amounts, a change in annual income, the receipt of loan repayment assistance from another program, any unusual change in the level of assets previously reported on my application, a change in marital status, any change of residential address or any other personal contact information, or any other change that would affect either my eligibility or the amount of my benefits under the Program. If selected to receive loan repayment assistance, I agree to submit a copy of the federal income tax return(s) for me and my spouse, if any, for any year in which I receive assistance on or before June 1st of the following year. If selected to receive loan repayment assistance, I also agree to cooperate with publicity efforts. Notre Dame Law School may use my name, photograph, and information about my public service work to publicize the Loan Repayment Assistance Program, both within the university community and to outside audiences in print, electronic, or any other format. Applicant s Signature Date Spouse s Signature Date