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MONTANA INSTITUTIONAL
NURSING INCENTIVE
PROGRAM
PROGRAM APPLICATION AND INSTRUCTIONS
Applications for the Montana Institutional Nursing Incentive Program are reviewed and considered once each
year. The current application cycle is now open with an application deadline of June 1, 2015.
Only original applications will be accepted; please do not scan or fax your application. Late and incomplete
applications will not be considered. It is the applicant’s responsibility to ensure all items are received by the
Office of the Commissioner of Higher Education (OCHE) by the deadline. The number and amount of awards
will be determined based upon the pool of eligible applicants and available state funding. Eligible applicants
can apply for program benefits for a maximum of four years. Please refer to 20-26-1511, MCA for further
information regarding this program.
To qualify for loan repayment consideration, you must:
•
Be a registered professional nurse licensed by the Montana Board of Nursing, pursuant to § 37-8-406,
MCA, who is employed full-time by either the Montana State Prison or the Montana State Hospital.
Priority is given to professional nurses who have been employed for a period of at least one year.
The attached Employment and Nursing License Verification Affidavit is to be completed by your
employer’s Human Resource Department and must accompany your application materials when
submitted to OCHE.
•
Submit proof of your nursing educational loans and have an existing loan balance of at least
$1,000.00. “Educational loans” for this purpose shall mean any loan made to the student pursuant to
a federal or private educational loan program, except federal parent loans for undergraduate students
(PLUS) loans, as provided in 20 USC § 1078-2. Personal private loans do not qualify for loan
repayment. Only loans incurred specifically to obtain your nursing education qualify for loan
repayment. Verification of consolidated loans must include a breakdown from the lender identifying
the original loan amounts and original disbursement dates. The attached Loan Information and
Verification Form must be completed by both you and your lender. Once it is complete, attach a copy
of your most recent student loan statement and submit along with the loan verification form with your
other application materials.
NOTE: Qualified nursing education loans being repaid under a federal loan repayment program
are not eligible for repayment under the Montana Institutional Nursing Incentive Program. State
and federal loan repayment benefits may not be received simultaneously.
Applications are to be mailed to the following address:
OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION
MONTANA UNIVERSITY SYSTEM
ATTN: LAURIE TOBOL
2500 BROADWAY
PO BOX 203201
HELENA, MT 59620-3201
CURRENT APPLICATION CYCLE DEADLINE – JUNE 1, 2015
Further information regarding the program and application process may be obtained by contacting Laurie Tobol with the Office
of the Commissioner of Higher Education at (406) 444-0322 or by email at: ltobol@montana.edu.
-1-
APPLICANT CHECKLIST AND INSTRUCTIONS
Application Materials to be completed by nursing applicants*:
Pages 1 and 2 of the Montana Institutional Nursing Incentive Program Application Form
Page 1 (Part A) of the Loan Information and Verification form for each medical education lender to be considered
for loan repayment
1. Submit the completed page 1 along with the incomplete page 2 to the lending institution(s)
2. If loan(s) is/are consolidated, the individual loan amounts and original loan dates for all loans contained within
the consolidation must be documented
*Additional documents may be requested if necessary upon initial review of application.
Application Materials to be completed and submitted by Supporting Institution:
Page 2 of the Montana Institutional Nursing Incentive Program Application Form
Application Materials to be completed and submitted by Lending Institution(s):
Page 2 (Part B) of the Loan Information and Verification form for each medical education lender to be considered
for loan repayment
1. The lending institution should return both completed pages back to the applicant to submit with application
Instructions:
•
•
•
•
Print legibly in blue or black ink or type your application and loan information and verification forms.
Complete all application materials clearly and completely. Incomplete applications will not be accepted.
Include your last, first, and middle name; full middle name is required. If your legal name does not include a
middle name, please indicate “No Middle Name”, DO NOT LEAVE BLANK.
Current mailing address and telephone number must reflect where you can be reached throughout the entire
application year. If you move or your contact information changes, notify our office immediately via email to:
ltobol@montana.edu
Completed applications and supporting documentation should be returned no later than
June 1, 2015 to the address listed above.
Please contact our office with any questions.
-2MONTANA INSTITUTIONAL NURSING INCENTIVE PROGRAM
APPLICATION FORM - SECTION 1
NAME:
(TO BE COMPLETED BY NURSE APPLICANT)
__________________________________ _________________________________ ________________________________ ______________________________
(Last)
(First)
(Middle)
(Maiden)
DATE OF BIRTH:
____________________________________
SOCIAL SECURITY NUMBER: ___________________________________________
HOME ADDRESS:
_____________________________________
BUSINESS NAME & ADDRESS: __________________________________________
PLACE OF BIRTH:
HOME PHONE:
_____________________________________
_____________________________________
_____________________________________
EMAIL ADDRESS: ________________________________________________________
_____________________________________________________________________________
BUSINESS PHONE: _______________________________________________________
HIGH SCHOOL GRADUATION: ________________________________________________________________________________________ ______________________
(Name and Location of High School)
(Graduation Date)
SCHOOL ATTENDED FOR NURSING EDUCATION: _______________________________________________________________________________________
(Name and Location of School)
DATES ATTENDED: ________________________________ DEGREE AWARDED: _____________________________ AWARD DATE: _________________
EXISTING NURSING EDUCATIONAL LOANS:*
Name of Lending Institution
Mailing Address
Phone Number
Account Number
Account Balance
* Please complete a separate loan verification form for each loan being submitted for loan repayment consideration.
STATE FACILITY CURRENTLY EMPLOYED AT:
Montana State Prison
Montana State Hospital
HAVE YOU APPLIED FOR OR ARE YOU CURRENTLY RECEIVNG LOAN REPAYMENT BENEFITS FOR THESE LOANS FROM ANY
OTHER PROGRAM?
Yes
No
If yes, please indicate the name of the program and date upon which participation/obligation started and will end.
________________________________________________________________
(Name of Program)
______________________________
(Start Date)
______________________________
(End Date)
NOTE: Qualified nursing education loans being repaid under a federal loan repayment program are not eligible for repayment
under the Montana Institutional Nursing Incentive Program. State and federal loan repayment benefits may not be received
simultaneously.
I certify that the information contained on this application is true and correct. I understand that I am not guaranteed an award
and that I have the specific responsibility of re-applying for the Institutional Nursing Incentive Program each year in order to
receive consideration. I also grant the financial institution listed on the loan verification form to release all information
regarding my student loan(s) to the Office of the Commissioner of Higher Education.
__________________________________________________________
(Signature of Nurse)
____________________________
(Date)
-3MONTANA INSTITUTIONAL NURSING INCENTIVE PROGRAM
APPLICATION FORM - SECTION 2
(TO BE COMPLETED BY EMPLOYING FACILITY)
EMPLOYING INSTITUTION:
PHONE:
Montana State Hospital
100 Garnet Way
Warm Springs, MT 59756
_________________________________________________________________
CONTACT: _________________________________________________________________
(Name and Title)
Montana State Prison
500 Conley Lake Road
Deer Lodge, MT 59722
FAX:
____________________________________________________
EMAIL: ____________________________________________________
EMPLOYMENT & NURSING LICENSE VERIFICATION AFFIDAVIT
I HEREBY CERTIFY THAT ________________________________________________________________________ IS CURRENTLY EMPLOYED AT THE
(Name of Nurse Applicant)
Montana State Hospital
Montana State Prison
AS A FULL-TIME REGISTERED PROFESSIONAL NURSE AND THAT HE/SHE IS CURRENTLY LICENSED IN THE STATE OF
MONTANA AS A PROFESSIONAL REGISTERED NURSE IN GOOD STANDING.
THIS FULL-TIME EMPLOYMENT BEGAN ON __________________________________, AND HAS BEEN CONTINUOUS THROUGH THE
CURRENT DATE:
Yes
(Date)
No
IF NOT, EMPLOYMENT STARTED ON ________________________________________, AND ENDED ON ________________________________________.
(Date)
(Date)
___________________________________________________________________
(Signature)
___________________________________________________________________
(Title)
__________________________________________________________________
(Date)
LOAN INFORMATION AND VERIFICATION FORM
THE MONTANA INSTITUTIONAL NURSING INCENTIVE PROGRAM
MONTANA UNIVERSITY SYSTEM
OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION
2500 BROADWAY
HELENA, MT 59620-3201
The following information must be provided for each individual loan you are submitting for repayment consideration under the
Montana Institutional Nursing Incentive Program. Print clearly or type completely to help expedite verification. Please note that
incomplete information may delay verification of your loan(s). Once the lending institution has completed their section of the form,
please attach a current statement of account to the completed forms and submit with your application materials.
APPLICANT: PLEASE COMPLETE ONE COPY OF THIS FORM FOR EACH LOAN YOU ARE SUBMITTING FOR REPAYMENT CONSIDERATION UNDER THE
MONTANA INSTITUTIONAL NURSING INCENTIVE PROGRAM. PLEASE PRINT CLEARLY AND BE SURE TO COMPLETE ALL OF PART A TO EXPEDITE
VERIFICATION. UPON COMPLETION OF PART A, SEND THIS FORM TO YOUR LENDER TO COMPLETE THE VERIFICATION CONTAINED UNDER PART B
AND HAVE THEM RETURN THE COMPLETED FORM BACK TO YOU. THEN SUBMIT BOTH COMPLETED FORMS (PART A AND PART B) WITH YOUR
CURRENT STATEMENT OF ACCOUNT AND APPLICATION MATERIALS TO THE OFFICE OF THE COMMISSIONER OF HIGHER EDUCATION (OCHE).
LENDING INSTITUTION: PLEASE COMPLETE PART B ON THE NEXT PAGE OF THIS FORM AND RETURN TO THE APPLICANT IDENTIFIED IN PART A.
PART A – TO BE COMPLETED BY APPLICANT
I. APPLICANT AND LENDING INSTITUTION INFORMATION:
________________________________ ________________________________ ______________________________ ___________________________ __________________________
Applicant Last Name
First Name
Middle Name
Birthdate
Social Security Number
______________________________________________________ ________________________________ __________ _____________________ ______________________________
Address (Street and/or PO Box)
City
State
Zip
Telephone Number
______________________________________________________ ______________________________ ______________________________ _________________________________
Lending Institution Name
Telephone Number
Fax Number
Loan Account Number
___________________________________________________________________________ _________________________________________ __________ _____________________
Address of Lending Institution (Street and/or PO Box)
II. LOAN INFORMATION:
City
State
Zip
Purpose of Loan: ________________________________________________________________ Type of Loan: _____________________________________________
(As indicated on loan application)
(Stafford, Health Professions, etc.)
Loan Account Number: _________________________________________________________ Original Date of Loan: ____________________________________
Original Amount of Loan: ______________________________________________________ Current Balance: __________________________________________
Is this a consolidated loan?*
Yes
No
Current Balance Date: ____________________________________
*FOR CONSOLIDATED UNDERGRADUATE AND GRADUATE EDUCATION LOANS: If you have consolidated your loans for undergraduate and graduate
education costs, you must attach documentation outlining the individual loan numbers, loan dates, and loan amounts that were consolidated
into the new loan.
WARNING: Any person, who knowingly makes a false statement or misrepresentation in this loan repayment transaction,
fraudulently obtains repayment for a loan, or commits any other illegal action in connection with this transaction is subject to
repaying any amount received from this program plus 8% interest. I have read this statement and understand its contents.
CERTIFICATION AND ACCOUNT AUTHORIZATION BY APPLICANT:
I hereby certify to the accuracy of the above information and apply to enter into an agreement with the Office of the Commissioner
of Higher Education for repayment towards the nursing education loans I have submitted with my application hereof. These loans
were incurred solely for the costs of nursing education. I hereby authorize the financial institution named in Section I from
above to release all loan account information to the Montana University System, OCHE for purposes of my participation in
the Montana Institutional Nursing Incentive Program from this point forward throughout the duration of my loan
repayment program participation as necessary.
____________________________________________________________________________________________________
Signature of Applicant
__________________________________________
Date
-2-
LOAN INFORMATION AND VERIFICATION FORM
THE MONTANA INSTITUTIONAL NURSING INCENTIVE PROGRAM
PART B – TO BE COMPLETED BY LENDING INSTITUTION
The individual identified on the first page of this form has applied to participate in the Montana Institutional Nursing Incentive
Program and states that, to the best of his/her knowledge, the loan information provided is a bona fide legally enforceable
commercial, state, government, or private educational loan (no personal loans) made for the purpose of meeting the borrower’s
costs of attending a school for nursing. Please verify this information according to your records by completing the information
below.
Account Holder Name:
Account Number:
Original Amount of Loan:
Original Date of Loan:
Current Loan Balance:
Lending Institution/Loan Servicer*:
(Payment Address)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
(For consolidations, please include details regarding the original loans/amounts included in consolidation.)
_____________________________________________________________________________________________________
(For consolidations, please include details regarding the original loans/dates included in consolidation.)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
(Name)
_____________________________________________________________________________________________________
(Mailing Address)
______________________________________________________________ ____________ _________________________
(City)
(State)
(Zip)
_________________________________________________ ___________________________________________________
(Telephone)
(FAX)
_____________________________________________________________________________________________________
(Federal Tax ID Number)
*LENDER – SUBMIT COPY OF W-9 WITH VERIFICATION FORM (required for Payment Processing)
Person to contact regarding current loan balance prior to disbursements:
________________________________________________________________
(Name)
________________________________________________________________
(Department)
________________________________________________________________
(Telephone)
Comments:
I hereby certify to the accuracy of the loan information contained on the first page of this form or as provided by the above
notations and comments.
________________________________________________________________
(Signature)
________________________________________________________________
(Title)
________________________________________________________________
(Date)
PLEASE RETURN THIS FORM TO THE APPLICANT IDENTIFIED IN PART A ON THE PREVIOUS PAGE.