GEORGE WASHINGTON LAW SCHOOL LOAN REPAYMENT ASSISTANCE PROGRAM INITIAL APPLICATION FORM. Name: Graduation year: Address: Home phone: Other phone:

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1 GEORGE WASHINGTON LAW SCHOOL LOAN REPAYMENT ASSISTANCE PROGRAM INITIAL APPLICATION FORM Name: _ Graduation year: Address: Home phone: Other phone: Social Security: Marital status (check one): Married Single Name of spouse, partner in civil union or domestic partnership (if any): Number of minor, dependent children living with you (if any): Name Age Solely/Jointly supported? Briefly describe any previous public interest experience, listing any organizations for which you worked or volunteered.

2 Information about your Employer Employer: Phone: Address: Supervisor: Phone: Starting date: Title: Yes No Is this employer a non-profit, IRS Code 501(c)(3), 501(c)(4), or 501(c)(5) organization? Is this employer a for-profit employer that devotes fifty percent or more of its hours to legal services provided on a pro bono, low fee, or court-awarded fee basis? Is this employer a government agency? Is this full-time employment? Does your employer require that a person in your position be a law school graduate? How does your employer assist underrepresented, indigent individuals or populations? How will your work benefit underrepresented, indigent individuals or populations? What percentage of your working hours will be devoted to work on behalf of indigents or other under-represented populations?

3 Information about your Income and Assets Gross income (before taking out any deductions): (specify if amount is for a week, biweekly, a month, year): $ every Other law loan repayment assistance: Other taxable income: $ every Source of this income: Any other income or in-kind benefit you receive (explain): If married, in civil union, or domestic partnership, etc., and partner is employed, please provide gross income from employment of partner: $ every Other taxable income of partner? $ every Source of this income: Partner s Employer: Address: Phone: ASSETS SELF PARTNER Cash, savings and checking accounts: $ $ Value of home (renters write 0 ): Other real estate: Business or farm ownership: Stocks, bonds, CDs, investments: Retirement account (e.g., 401(k)) (value as of last day of last year) Beneficiary of contingent trust funds worth: Beneficiary of vested trust funds: IRA value (as of last day of last year) Keogh value (as of last day of last year)

4 REGULAR PAYMENTS: Information about your Expenses and Loans Current monthly rent or mortgage payment $ If you own a car, monthly car payment Make: Year Child support paid: $ every Monthly payments for non-law-school, student loans: $ Spouse s monthly educational loan payments: $ LAW SCHOOL LOANS Assistance is provided for loans incurred to attend law school or to take a bar exam, not to attend college or to obtain another graduate degree. If you have consolidated loans, you must provide documentation regarding both the original and consolidated loans, showing which loans were consolidated, on what terms, and what portion of the debt pertains to your law school education. Please complete the Loan Information Sheet. Use additional sheets if necessary. ATTACHMENTS Please attach to your completed application copies of these documents: 1. Resume 2. Transcript 3. Federal tax forms for the last year (1040, 1040EZ, etc.) for self and spouse/partner 4. All attachments to federal tax forms for the last year including W-2 forms for self and spouse/partner 5. Signed employer certification form 6. Completed Loan Information Sheet and supporting documentation:

5 for each loan listed, provide documentation showing date of loan, lender, loan amount, payment amount and schedule, payment period (# of years), start date for payment, and interest rate. 8. Copy of recent wage/salary statement from employer (if available) for self and spouse/partner. 9. Any additional sheets needed to explain the responses above. CERTIFICATION I,, hereby certify that the information contained in this Application and the Attachments thereto is accurate and complete, to the best of my knowledge, and is submitted in good faith. I understand that providing inaccurate or misleading information could result in denial of my application for an LRAP loan. I understand that if any of the information included in this application becomes inaccurate because of a change (deferral of loans, change marital status, employment, benefits, etc.), that I will contact the LRAP Committee in writing (including ) immediately to notify them of the change. Date Signature LRAP Committee contacts: Tamara Devieux-Adams Suzanne Jackson tdadams@law.gwu.edu sjackson@law.gwu.edu