Form NIH-2851-2 Student Loan Repayment Program Service Agreement

Form NIH-2851-2 is a U.S. Department of Health and Human Services - National Institutes of Health form also known as the "Student Loan Repayment Program Service Agreement". The latest edition of the form was released in May 1, 2018 and is available for digital filing.

Download a fillable PDF version of the Form NIH-2851-2 down below or find it on U.S. Department of Health and Human Services - National Institutes of Health Forms website.

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Student Loan Repayment Program Service Agreement
NAME (Print or type first, middle, last)
Social Security Number
Institute or Center
Date
In consideration of the student loan repayment benefit for which I qualify under 5 U.S.C. 5379 as implemented by the
regulations of the U.S. Office of Personnel Management (5 CFR, Part 537), the policies of the Department of Health
and Human Services, and the National Institutes of Health, I hereby agree that:
1. I will serve at the National Institutes of Health (NIH) for
3 years (initial contract) or
an additional 1-year
extension.
(up to $10,000, gross, per calendar year).
2. The amount of the student loan repayment benefit is $
3. If student loan repayment benefits are made in the 2nd or 3rd year, my service agreement will not be extended;
however, the service agreement will be modified to reflect any additional loans disbursed.
4. If student loan repayment benefits are made beyond 3 years, my service agreement will be extended by one year for
each payment made beyond the 3rd year.
5. The service agreement is effective
(month/day/year) through
(month/day/year). Example: 10/14/2014 through 10/13/2017 for an initial service agreement.
[Note: The actual service agreement dates will be completed by WRD/BPLB when the action is processed and noted
on the SF-50 documenting the action. Employees are responsible for checking the service dates once processed.]
6. The amount of student loan repayment will not exceed the loan balance outstanding at the signing of the service
agreement, or upon modification of the service agreement, for the period of the service agreement, including
extensions.
7. In the event that I voluntarily leave NIH, or in the event that I am involuntarily separated for misconduct or performance
before completing the initial 3-year service agreement period, I will be indebted to the Federal Government and must
reimburse NIH for the full amount of any student loan repayment benefits received under this service agreement.
However, if I fail to complete the period of service under an extension period, (e.g., 4
year, 5
year) I understand that
th
th
I must repay the amount of the benefits received in the extension year only.
8. I am responsible for making loan payments on the portion of the loan that continues to be my responsibility.
9. The student loan repayment benefits made do not exempt me from my responsibility and/or liability for the loan.
10. I am responsible for any income tax obligation resulting from the student loan repayment benefit. I understand that
the appropriate taxes will be deducted or applied at the time payment is made.
11. NIH is not responsible for late fees assessed by the lender if the student loan repayment benefit is not received on time.
12. The student loan repayment benefits made on my behalf from the Federal Government will not exceed $10,000 (gross)
per calendar year or the lifetime maximum amount of $60,000 (gross).
13. This service agreement in no way constitutes a right, promise, or entitlement for continued employment or
noncompetitive conversion to the competitive service. Acceptance of this agreement does not alter the conditions or
terms of my employment; accordingly, this agreement will not preclude nor limit the NIH from effecting personnel
actions as may be appropriate.
Payments may be applied only to indebtedness outstanding at the time the service agreement is signed, modified, or
14.
extended. In years 1 through 3, the service agreement period may not be extended, but it may be modified to reflect
that additional qualifying loans have been added to the outstanding loan balance, with verification from the lender.
Check here if the initial service agreement is being modified or extended:
I AGREE TO THE TERMS OF THIS SERVICE AGREEMENT:
Signature
Name (print/type)
Date
NIH 2851-2 (05/18)
(Front)
Student Loan Repayment Program Service Agreement
NAME (Print or type first, middle, last)
Social Security Number
Institute or Center
Date
In consideration of the student loan repayment benefit for which I qualify under 5 U.S.C. 5379 as implemented by the
regulations of the U.S. Office of Personnel Management (5 CFR, Part 537), the policies of the Department of Health
and Human Services, and the National Institutes of Health, I hereby agree that:
1. I will serve at the National Institutes of Health (NIH) for
3 years (initial contract) or
an additional 1-year
extension.
(up to $10,000, gross, per calendar year).
2. The amount of the student loan repayment benefit is $
3. If student loan repayment benefits are made in the 2nd or 3rd year, my service agreement will not be extended;
however, the service agreement will be modified to reflect any additional loans disbursed.
4. If student loan repayment benefits are made beyond 3 years, my service agreement will be extended by one year for
each payment made beyond the 3rd year.
5. The service agreement is effective
(month/day/year) through
(month/day/year). Example: 10/14/2014 through 10/13/2017 for an initial service agreement.
[Note: The actual service agreement dates will be completed by WRD/BPLB when the action is processed and noted
on the SF-50 documenting the action. Employees are responsible for checking the service dates once processed.]
6. The amount of student loan repayment will not exceed the loan balance outstanding at the signing of the service
agreement, or upon modification of the service agreement, for the period of the service agreement, including
extensions.
7. In the event that I voluntarily leave NIH, or in the event that I am involuntarily separated for misconduct or performance
before completing the initial 3-year service agreement period, I will be indebted to the Federal Government and must
reimburse NIH for the full amount of any student loan repayment benefits received under this service agreement.
However, if I fail to complete the period of service under an extension period, (e.g., 4
year, 5
year) I understand that
th
th
I must repay the amount of the benefits received in the extension year only.
8. I am responsible for making loan payments on the portion of the loan that continues to be my responsibility.
9. The student loan repayment benefits made do not exempt me from my responsibility and/or liability for the loan.
10. I am responsible for any income tax obligation resulting from the student loan repayment benefit. I understand that
the appropriate taxes will be deducted or applied at the time payment is made.
11. NIH is not responsible for late fees assessed by the lender if the student loan repayment benefit is not received on time.
12. The student loan repayment benefits made on my behalf from the Federal Government will not exceed $10,000 (gross)
per calendar year or the lifetime maximum amount of $60,000 (gross).
13. This service agreement in no way constitutes a right, promise, or entitlement for continued employment or
noncompetitive conversion to the competitive service. Acceptance of this agreement does not alter the conditions or
terms of my employment; accordingly, this agreement will not preclude nor limit the NIH from effecting personnel
actions as may be appropriate.
Payments may be applied only to indebtedness outstanding at the time the service agreement is signed, modified, or
14.
extended. In years 1 through 3, the service agreement period may not be extended, but it may be modified to reflect
that additional qualifying loans have been added to the outstanding loan balance, with verification from the lender.
Check here if the initial service agreement is being modified or extended:
I AGREE TO THE TERMS OF THIS SERVICE AGREEMENT:
Signature
Name (print/type)
Date
NIH 2851-2 (05/18)
(Front)
This information may also be disclosed to the Department of
Privacy Act Notification Statement
Justice for other lawful purposes including law enforcement
Collection of this information is authorized under 5
and in the event of litigation. In addition, these records, or
U.S.C. 5379. The purpose of collecting the information is
information therefore, may also be used within DHHS for
to establish terms under which an individual receives a
study purposes, such as projection of staffing needs, and/or
student loan repayment benefit under the Student Loan
creation of non-identifiable statistical data for reports to other
Repayment Program. The information will be used as a
Federal agencies and Congress.
basis for payroll actions. This information may be
disclosed to the Internal Revenue Service for tax
Information Regarding Disclosure of Your Social
withholding purposes, the Department of Treasury for
Security Account Number
payroll action, the Department of Labor for worker
Disclosure of the SSN is mandatory since it is the identifier
compensation claims and the Department of Justice for
used by the Internal Revenue Service and for the
other lawful purposes including law enforcement and in
withholding of taxes from your salary. The use of the SSN is
the event of litigation. In addition, this information may
made necessary because of the large number of present
be used within DHHS for study purposes, such as
and former employees and applicants who have identical
projection of staffing needs, and/or creation of non-
names and birth dates, and whose identities can only be
identifiable statistical data for reports to other Federal
distinguished by the SSN. It is used primarily to identify an
agencies and Congress. The request for this information
employee's personnel, leave, and pay records and to relate
is voluntary, however, if information is not provided it
on to the other. In this regard, it is also used by the HHS to
could preclude the processing of the student loan
locate records in order to respond to lawful requests for
repayment benefits request. Statement is pursuant to
information from former employers, educational institutes,
the Privacy Act of 1974 (P.L. 93-597)
and financial or other organizations. The information
gathered through the use of the number will be used only as
Authority for Collection of Information: 5 U.S.C 5379.
necessary in personnel administration processes carried out
Purpose and Uses
in accordance with established regulations and published
notices of systems of records. The SSN also will be used for
The main purpose for collecting the information
the selection of persons to be included in statistical studies
requested on the above mentioned form is to establish
of personnel management matters.
the terms under which an individual receives a student
loan repayment benefit under the Student Loan
Effect of Non-disclosure
Repayment Program. The information collected will be
used as a basis for payroll actions. Accordingly,
Your submission of this agreement is voluntary; however, if
disclosure of identifiable information, including your
the agreement is submitted, omission of significant
Social Security Number (SSN), may be made to the
information requested would preclude continued processing
Internal Revenue Service for tax withholding purposes,
of the agreement for you to receive an allowance because
the Department of Treasury for payroll action, and to the
payroll would be unable to process the necessary actions.
Department of Labor for worker compensation claims.
NIH 2851-2 (05/18)
(Back)

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