QUINNIPIAC UNIVERSITY SCHOOL OF LAW GREGORY A. LOKEN LOAN REPAYMENT ASSISTANCE PROGRAM 2019 APPLICATION

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1 QUINNIPIAC UNIVERSITY SCHOOL OF LAW GREGORY A. LOKEN LOAN REPAYMENT ASSISTANCE PROGRAM 2019 APPLICATION Thank you for your interest in the Gregory A. Loken Loan Repayment Assistance Program (LRAP). If you have not already done so, please review the LRAP eligibility criteria, which you can find in the Financial Aid section of the Law School's website. If you have received an LRAP award in the past, you may apply for consideration for the 2019 LRAP award year. You must, however, submit a complete 2019 application. To be considered for the 2019 LRAP award year, your application MUST BE POSTMARKED BY APRIL 1, We will NOT consider your application complete and we CANNOT evaluate it until you submit ALL the information listed below. (Please check off each item to insure your application package is complete.) 1. A statement indicating whether you have received a LRAP award in a prior year. 2. A short, 1-2 page, personal statement that describes your eligible employment, how it serves the public, and how it meets the goals of the LRAP program. 3. A letter from your employer verifying your eligible employment. The letter must include your annual salary your starting date, and the name of a contact person. 4. Applicant Information (Page 2). 5. Income Information (Page 3).If you are receiving loan repayment assistance from another source, please provide that information. 6. Asset Information (Page 4). 7. Expense and Indebtedness Information (Page 5). 8. Educational Debt Information (Pages 6-7). 9. Certification (Page 8). 10. Copies of your (and, if applicable, your spouse's) 2017 federal and state income tax returns (unless you were not required by law to file returns for 2017) with a copy of your (and, if applicable, your spouse's) 2017 W-2s attached. If you (or your spouse) were not required to file a 2017 tax return, please supply a signed statement that you were not required to file. Although the physical location for the law school is in North Haven, all mail is sent to the Hamden address. MAIL COMPLETED APPLICATION AND SUPPORTING MATERIALS TO: Quinnipiac University School of Law Office of the Dean LW-DEN RE: LRAP APPLICATION 275 Mount Carmel Avenue Hamden, CT ACKNOWLEDGEMENT OF RECEIPT AND ALL CORRESPONDENCE TO APPLICANTS WILL BE SENT BY .

2 Page 2 A. Applicant Information: Name: Social Security Number: Law School Graduation Date: Home Address: Address: Telephone Number: ( ) Marital Status * : Name(s) and age(s) of dependent children under the age of 21: B. Applicant Employment Information: Eligible Employer: Address: Telephone Number: ( ) Position/Job Title: Starting Date of Employment: Current (or Expected) Annual Gross Income: If not yet employed or if less than 6 months on current job, please list previous employment for the last two years: C. Spouse's ** Employment Information: Name of Spouse: Employer: Address: Telephone Number: ( ) Position/Job Title: Starting Date of Employment: Current Annual Gross Income: * Marital status" includes all relationships legally sanctioned under state law, including, in addition to marriage, civil unions, and registered domestic partnerships. ** Spouse includes anyone with whom the applicant has entered into a legally sanctioned relationship under state law.

3 Page 3 INCOME INFORMATION Name: QUSL Graduation Date: Single, Married, Living with Spouse: Please report income for the period of January 1 through December 31, 2018 and your estimated income for the period of January 1 through December 31, If you are married, you must also report your spouse s income. Applicant Spouse 2018 Est Est Wages and Salaries Overtime/Bonus/Commissions Total Interest Income Total Dividend Income Net Business Income Alimony/Child Support Received Unemployment Compensation Rental Income Trust Fund Income Other LRAP Assistance (Identify Source) Other Income Specify Total If not reported above, please provide information about substantial financial contributions or support you, and/or, if applicable, your spouse has received from any source since January 1, 2017: Comments (optional if necessary to explain income information):

4 Page 4 ASSET WORKSHEET Applicant Spouse Cash and Bank Accounts Brokerage Accounts Pension/Retirement Accounts Home Equity *** Other Real Estate and Investment Equity Trust or Inheritance Funds Vehicle **** Other Assets Total Comments (optional if necessary to explain asset information): *** Market value of home: $ Amount still owed on home: $ **** Market value of vehicle(s): $ Amount still owed on vehicle(s): $

5 Page 5 EXPENSE AND INDEBTEDNESS INFORMATION NOTE: Include, in addition to your own expenses and indebtedness information, that of your spouse. Monthly Expenses: Rent and/or monthly mortgage: Utilities (specify): Food: Entertainment: Insurance (medical, dental, etc.): Applicant: Spouse: Transportation costs: Childcare costs: Child support payments: Applicant: Spouse: Student loan payments: Applicant: Spouse: Other expenses (specify car payment, credit card payments, other loan payments, etc.): Comments (optional if necessary to explain expense and indebtedness information

6 Page 6 EDUCATIONAL DEBT FROM QUINNIPIAC UNIVERSITY SCHOOL OF LAW Please list below each loan for which you are or will be making monthly payments. If you are in repayment, this list must be accompanied by your most recent loan statement(s) from your lender(s) showing your outstanding loan amount and payment history. If you have not yet begun to make payments on your loans, this list must be accompanied by a statement of your loan balances from your lender(s). Most lenders provide this information to you on their website in the borrower services area. If you have consolidated your loans, this list must be accompanied by a breakdown of the loans included in the consolidation. Loan Type Lender Servicer Total Amount Borrowed Monthly Payment Subsidized Federal Stafford Loans Unsubsidized Federal Stafford Loans Federal Graduate Plus Loans Private Loans Federal Consolidated Loans EDUCATIONAL DEBT FROM OTHER INSTITUTIONS Loan Type Lender Servicer Total Amount Borrowed Monthly Payment Subsidized Federal Stafford Loans Unsubsidized Federal Stafford Loans Federal Graduate Plus Loans Federal Perkins Loan Private Loans Federal Consolidated Loans Comments (optional if necessary to explain educational debt information):

7 Page 7 SPOUSE'S EDUCATIONAL DEBT, IF APPLICABLE Following the same guidelines as above, please list below each loan for which your spouse is or will be making monthly payments. Loan Type Lender Servicer Total Amount Borrowed Monthly Payment Subsidized Federal Stafford Loans Unsubsidized Federal Stafford Loans Federal Graduate Plus Loans Federal Perkins Loan Private Loans Federal Consolidated Loans Comments (optional if necessary to explain educational debt information):

8 Page 8 CERTIFICATION 1. I hereby certify that all of the information contained in this application and supporting materials is true and accurate to the best of my knowledge. 2. I agree to provide supporting documentation of the information I have given on this application, if requested. 3. I certify that I will use all LRAP funds I receive for the express purpose of repaying student loans. 4. I agree to notify the Office of the Dean, in writing, within 30 days of any change in my employment. If, upon such notice, I am no longer in a position that qualifies for LRAP assistance, I understand that my award may be prorated to the date that I leave eligible employment, and all future award benefits will cease. 5. I understand that if I am not current in payment on any of my educational loans I will be terminated from LRAP participation. 6. I agree to notify the Office of the Dean, in writing, if I receive a deferment or forbearance on any of my student loans from my lender, and/or if my loan payments are reduced after my LRAP benefit award is calculated. 7. I agree to notify the Office of the Dean, in writing, within 30 days of any change in income, assets, employment, marital status, or if I file a bankruptcy petition. 8. I certify that I am not receiving any assistance in the repayment of any of my student loans from any source not reported on this application. 9. I understand that in order to receive LRAP funds for the 2019 award year I must sign a promissory note providing for my repayment of LRAP funds to QUSL in the event I default on any of the obligations set forth in the program description. 10. I understand that receipt of an LRAP award for the 2019 award year does not entitle me to any award for future years, and that I must reapply with all other applicants in future years. 11. I understand that the deadline for submission of this application and all supporting materials listed on the first page of this application for the 2019 LRAP award year is April 1, I certify that I have read and understand the material explaining all eligibility requirements for the Gregory A. Loken Loan Repayment Assistance Program located at Applicant's Signature Date: Spouse's Signature Date: