Fillable Application for Canada Student Loan Forgiveness for Family (Government of Canada)

Fill Online, Printable, Fillable, Blank Application for Canada Student Loan Forgiveness for Family (Government of Canada) Form

Use Fill to complete blank online GOVERNMENT OF CANADA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for Canada Student Loan Forgiveness for Family (Government of Canada)

On average this form takes 21 minutes to complete

The Application for Canada Student Loan Forgiveness for Family (Government of Canada) form is 5 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 81 other fields

Country of origin: CANADA
File type: PDF

Use our library of forms to quickly fill and sign your Government of Canada forms online.

BROWSE GOVERNMENT OF CANADA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
HRSDC SDE0094 (2013-10-002) E
Page 1 of 5
Application for Canada Student Loan
Forgiveness for Family Doctors and Nurses
You must apply after the end of each 12-month loan forgiveness period.
Make sure you complete the entire application.
Your completed application must be received no later than 90 days after your 12 month loan
forgiveness period ends.
(A) About loan forgiveness
Many rural and remote communities in Canada lack the primary health care they need. That is why, since April 2013, the Government of Canada has
been offering Canada Student Loan forgiveness to eligible family doctors, residents in family medicine, nurse practitioners and nurses who work in
designated rural or remote communities*. This change will help more Canadians get the health care they deserve.
This benefit is intended to encourage family doctors, residents in family medicine, nurse practitioners and nurses to practice in under-served rural or
remote communities by forgiving a portion of Canada Student Loans.
Family doctors and family medicine residents may be eligible for forgiveness of $8,000 per year to a maximum of $40,000 over five years. Nurses and
nurse practitioners may be eligible for forgiveness of $4,000 per year to a maximum of $20,000 over five years.
*See Designated communities for definition.
(B) ELIGIBILITY
(C) Licensing requirements
You must have a valid licence from a province or territory to practice one of the following professions:
Nurses or Nurse Practitioners: Family Doctors
Nurse
Nurse Practitioner
Licensed Practical Nurse
Registered nurse
Registered practical nurse
Registered psychiatric nurse
Family doctor
Family physician
Family Medicine Resident (exempt from Licensing – although will be
verified with Province)
(D) Designated communities
(E) Loan forgiveness period
You select 12 consecutive months as your loan forgiveness period, during which you were employed or in practice in a designated rural or remote
community and you provided in person services for a minimum of 400 hours (or 50 days).
Note: You must complete a full 12-month loan forgiveness period before you can apply for this benefit. The next loan forgiveness period you wish to apply
for can begin after your previous loan forgiveness period has ended.
If you worked in more than one designated rural or remote community during your loan forgiveness period to accumulate a minimum of 400 hours (or 50
days) of in-person services, use Section 7 (and Section 2) to list the additional employment in chronological order. List your employment history during the
loan forgiveness period, starting with your most current employment situation and working back. The number of months that you identify for each
employment period in Section 2 and Section 7 must total 12 months to reflect a 12-month loan forgiveness period.
A designated community is a municipality (as determined by Statistics Canada) that is located outside of:
• census metropolitan areas;
• census agglomerations (geographic units) with an urban core population of 50 000 or more; and
• provincial capitals.
You are eligible to apply if you:
• are practicing in Canada as a family doctor, resident in family medicine, registered nurse, registered psychiatric nurse, registered practical
nurse, licensed practical nurse or nurse practitioner and meet the licensing requirements (see Licensing requirements);
• started your current employment in the designated community on or after July 1, 2011;
• have been employed (full-time, part-time or casually) for a full year (12 months) in a designated community and provided in-person services
for a minimum of 400 hours (or 50 days) in that community. The 12-month period you select is your loan forgiveness period (see Loan
forgiveness period);
• are in repayment and up-to-date on your Canada Student Loan payments (e.g. you cannot be enrolled in full-time studies); and
• have outstanding student loans from the Canadian federal government (lines of credit from financial institutions are not eligible).
You can verify if your place of work is in a designated rural or remote community by using the postal code lookup on the CanLearn.ca website (
http://
tools.canlearn.ca/cslgs-scpse/cln-cln/lfnd-erpm/1-eng.do). The name of your designated community is required to complete Section 2 – Employment
information and Section 7 – Additional employment information of the application and must match the postal code exactly to be accepted.
Note: The 12 months of your loan forgiveness period are considered consecutive when you do not have a break in service of more than one month. (See
Section 6 – Employment Insurance for the exceptions to this rule.)
In total, you can receive five periods of Canada Student Loan forgiveness. These periods do not need to be consecutive; however, they cannot overlap.
HRSDC SDE0094 (2013-10-002) E
Page 2 of 5
Make sure you provide all of the information requested in this section.
The designated community must match the community identified by the postal code lookup tool on CanLearn.ca.
The loan forgiveness period must be 12 consecutive months.
If you have worked in multiple locations, you must complete Section 7. The number of months that you identify for each employment period in Section 2
and Section 7 must total 12 months to reflect a 12-month loan forgiveness period. Each section must be signed by the supervisor from that location.
(Signatures cannot be provided in an email or a letter.)
If you work for an employer, you must have your employer or immediate supervisor attest to the start and end dates of the 12-month loan forgiveness
period, as well as the number of hours (or days) you completed over that period. Your employer/immediate supervisor must sign and date the attestation.
(Signatures cannot be provided in an email or a letter.)
If you are self-employed (i.e. you have established a family medicine practice), you must have a local official attest that, to the best of his or her
knowledge, you provided the number of hours (or days) of in-person service during the 12-month loan forgiveness period. Local officials may include
elected officials such as the mayor or a member of a legislature, an official at a local hospital or a local band chief. The local official must sign and date the
attestation. (Signatures cannot be provided in an email or a letter.)
(H) SECTION 3 - Other Canada Student Loan balances with financial institutions
Identify the name(s) of the financial institution(s) where you have outstanding Canada Student Loan balances. If you do not have any outstanding student
loans with a financial institution, check the “Not Applicable” box.
(I) SECTION 4 - Automatic revision of terms
Once the loan forgiveness benefit is approved, a revision of terms will be processed to reduce your payment, keeping the term (number of payments) the
same. If you do not want to have your loan payment reduced, please initial in the space provided.
(J) SECTION 5 - Applicant attestation
Sign and date this section to attest that the information you have provided in your application for this benefit is valid.
(K) Section 6 - Employment Insurance
If you had a break in service of more than one month in the loan forgiveness period during which you were receiving any of the following Employment
Insurance benefits, you remain eligible to receive Canada Student Loan forgiveness:
HOW TO COMPLETE THE APPLICATION FORM
(F) SECTION 1 - Applicant Information
Make sure you provide all of the information requested in this section, including your registration or licence number.
(G) SECTIONS 2 - Employment Information
• Maternity benefits
• Parental benefits
• Sickness benefits
• Compassionate care benefits
• Benefit for parents of critically ill children
(L) SECTION 7 (a, b, c and d) - Additional employment information (if required)
If you worked in multiple designated communities during the loan forgiveness period, please provide the additional employment information in these
sections. The number of months that you identify for each employment period in Section 2 and Section 7 must total 12 months to reflect a 12 month loan
forgiveness period. Each section must be signed by the supervisor from that location.
(M) Apply by mail
Send your completed application to:
National Student Loans Service Centre
P.O. Box 4030
Mississauga, ON L5A 4M4
If you have any questions concerning your eligibility for Canada Student Loan forgiveness for Family Doctors and
Nurses, please contact the NSLSC Toll free at 1-888-815-4514 (within North America)
If you were receiving Employment Insurance benefits during the loan forgiveness period you have identified, please complete Section 6 – Employment
Insurance.
HRSDC SDE0094 (2013-10-002) E
Page 3 of 5
Human Resources and
Skills Development Canada
Ressources humaines et
Développement des compétences Canada
PROTECTED WHEN COMPLETED - B
SECTION 2 - Employment Information (see Instructions G)
Applicant's Valid Registration Number
Family Medicine Resident Licensed Practical Nurse
Nurse Practitioner
Family Doctor
Registered Psychiatric Nurse Registered Practical Nurse
Registered Nurse
Please list your most recent employer and the name and address of the medical facility/private practice in the designated community where you provided
in-person services during your loan forgiveness period. If you worked in more than one designated rural or remote community, list the additional
supporting employment history in Section 7.
CANADA STUDENT LOAN FORGIVENESS FOR FAMILY DOCTORS
AND NURSES APPLICATION FORM
Home Mailing Address
First Name Last Name
Postal CodeProvince
Social Insurance NumberTelephone Number
SECTION 1 - Applicant Information (see Instructions F)
City
Name and Mailing Address of Medical Facility/Private Practice Name of Designated Community
Postal Code
Employment Start Date at this Location
Month/Day/Year
Using the “From” and “To” fields, identify 12 consecutive months of employment during which you provided a minimum of 400 hours (or 50 days of service)
in a designated rural or remote community. This is your loan forgiveness period.
Note: If you were receiving Employment Insurance benefits during the loan forgiveness period you have identified, please complete Section 6 –
Employment Insurance.
From (Month/Day/Year) To (Month/Day/Year)
In-person services during the loan forgiveness period
No. of Hours Completed No. of Days Completed OR
Supervisor/Attestor Information
Supervisor/Attestor Phone No.TitleName of Immediate Supervisor/Attestor
Month/Day/year
Signature of Supervisor
I attest the applicant worked the indicated number of hours and/or days at the work address and medical facility/private practice indicated within the
period of time identified. I also attest that the applicant was not employed at this work address prior to July 1, 2011.
SECTION 3 - Other Canada Student Loan Balances with Financial Institutions (see Instructions H)
Name of Institution(s)
1
2
Not Applicable
SECTION 4 -Automatic Revision of Terms (see Instructions I)
If you are approved for loan forgiveness, once your loan balance has been reduced, your monthly loan payments will also automatically be reduced. If you
do not want to have your monthly loan payments reduced, initial the blank space and your monthly payments will remain the same (applicant
initials).
SECTION 5 - Applicant Attestation - To be completed by applicant in full (see Instructions J)
By signing below, I acknowledge that I am making an application to determine whether I qualify to receive loan forgiveness for doctors, residents in family
medicine, nurse practitioners and nurses practicing in designated rural or remote communities on my Canada Student Loans. I understand that it is an
offence to make a false or misleading statement, and that such a statement may result in legal action being taken against me. Furthermore, I understand
that administrative measures may be taken in respect of my student loans if such a statement is made. I acknowledge that the federal government and
any of its agents or contractors, the National Student Loan Service Centre, consumer credit grantor(s), credit bureau(s), credit reporting agency(ies), any
person or business with whom I have or may have had financial dealings and my financial institution(s) may directly or indirectly collect, retain, use,
disclose and exchange among themselves any personal information related to this application for the purposes of carrying out their duties under the
federal Act(s) and Regulation(s) including for administration, enforcement, debt collection, audit, verification, research and evaluation purposes. Where my
consent is required to permit the direct or indirect collection, retention, use or disclosure of personal information required by law, by signing below, I
provide my consent.
Signature of Applicant
Month/Day/Year
HRSDC SDE0094 (2013-10-002) E
Page 4 of 5
Section 6 – Employment Insurance
If you had a break in service of more than one month in the loan forgiveness period during which you were receiving any of the following Employment
Insurance benefits, you remain eligible to receive Canada Student Loan forgiveness:
• Maternity benefits
• Parental benefits
• Sickness benefits
• Compassionate care benefits
• Benefit for parents of critically ill children
Yes No
Did you receive any of these benefits?:
Additional employment information
Section 7a – Additional employer/community
Please list your additional employment information in this section as part of your loan forgiveness period. The number of months that you identify for each
employment period in Section 2 and Section 7 must total 12 months to reflect a 12 month loan forgiveness period. In addition to section 2, any information
provided in section 7a) b) c) d) must be signed by the supervisor from that location.
Name and Mailing Address of Medical Facility/Private Practice Name of Designated Community
Postal Code
Employment Start Date at this Location
Month/Day/Year
Using the “From” and “To” fields, identify the months of employment during which you contributed toward a minimum of 400 hours (or 50 days of service)
in a designated rural or remote community. These months are a part of your complete loan forgiveness period.
Note: If you were receiving Employment Insurance benefits during the loan forgiveness period you have identified, please complete Section 6 –
Employment Insurance.
From (Month/Day/Year) To (Month/Day/Year)
In-person services during the loan forgiveness period
No. of Hours Completed No. of Days Completed OR
Supervisor/Attestor Information
Supervisor/Attestor Phone No.TitleName of Immediate Supervisor/Attestor
Month/Day/year
Signature of Supervisor
I attest the applicant worked the indicated number of hours and/or days at the work address and medical facility/private practice indicated within the
period of time identified. I also attest that the applicant was not employed at this work address prior to July 1, 2011.
Section 7b – Additional employer/community
Please list your additional employment information in this section as part of your loan forgiveness period. The number of months that you identify for each
employment period in Section 2 and Section 7 must total 12 months to reflect a 12 month loan forgiveness period. In addition to section 2, any information
provided in section 7a) b) c) d) must be signed by the supervisor from that location.
Name and Mailing Address of Medical Facility/Private Practice Name of Designated Community
Postal Code
Employment Start Date at this Location
Month/Day/Year
Using the “From” and “To” fields, identify the months of employment during which you contributed toward a minimum of 400 hours (or 50 days of service)
in a designated rural or remote community. These months are a part of your complete loan forgiveness period.
Note: If you were receiving Employment Insurance benefits during the loan forgiveness period you have identified, please complete Section 6 –
Employment Insurance.
From (Month/Day/Year) To (Month/Day/Year)
In-person services during the loan forgiveness period
No. of Hours Completed No. of Days Completed OR
I consent for the Canada Student Loans Program to contact the Canada Employment Insurance Commission to verify that I was in fact on
Employment Insurance related leave during my loan forgiveness period identified in Section 2, if required, for the purpose of continued eligibility.
HRSDC SDE0094 (2013-10-002) E
Page 5 of 5
Supervisor/Attestor Information
Supervisor/Attestor Phone No.TitleName of Immediate Supervisor/Attestor
Month/Day/year
Signature of Supervisor
I attest the applicant worked the indicated number of hours and/or days at the work address and medical facility/private practice indicated within the
period of time identified. I also attest that the applicant was not employed at this work address prior to July 1, 2011.
Section 7c – Additional employer/community
Please list your additional employment information in this section as part of your loan forgiveness period. The number of months that you identify for each
employment period in Section 2 and Section 7 must total 12 months to reflect a 12 month loan forgiveness period. In addition to section 2, any information
provided in section 7a) b) c) d) must be signed by the supervisor from that location.
Name and Mailing Address of Medical Facility/Private Practice Name of Designated Community
Postal Code
Employment Start Date at this Location
Month/Day/Year
Using the “From” and “To” fields, identify the months of employment during which you contributed toward a minimum of 400 hours (or 50 days of service)
in a designated rural or remote community. These months are a part of your complete loan forgiveness period.
Note: If you were receiving Employment Insurance benefits during the loan forgiveness period you have identified, please complete Section 6 –
Employment Insurance.
From (Month/Day/Year) To (Month/Day/Year)
In-person services during the loan forgiveness period
No. of Hours Completed No. of Days Completed OR
Supervisor/Attestor Information
Supervisor/Attestor Phone No.TitleName of Immediate Supervisor/Attestor
Month/Day/year
Signature of Supervisor
I attest the applicant worked the indicated number of hours and/or days at the work address and medical facility/private practice indicated within the
period of time identified. I also attest that the applicant was not employed at this work address prior to July 1, 2011.
Section 7d – Additional employer/community
Please list your additional employment information in this section as part of your loan forgiveness period. The number of months that you identify for each
employment period in Section 2 and Section 7 must total 12 months to reflect a 12 month loan forgiveness period. In addition to section 2, any information
provided in section 7a) b) c) d) must be signed by the supervisor from that location.
Name and Mailing Address of Medical Facility/Private Practice Name of Designated Community
Postal Code
Employment Start Date at this Location
Month/Day/Year
Using the “From” and “To” fields, identify the months of employment during which you contributed toward a minimum of 400 hours (or 50 days of service)
in a designated rural or remote community. These months are a part of your complete loan forgiveness period.
Note: If you were receiving Employment Insurance benefits during the loan forgiveness period you have identified, please complete Section 6 –
Employment Insurance.
From (Month/Day/Year) To (Month/Day/Year)
In-person services during the loan forgiveness period
No. of Hours Completed No. of Days Completed OR
Supervisor/Attestor Information
Supervisor/Attestor Phone No.TitleName of Immediate Supervisor/Attestor
Month/Day/year
Signature of Supervisor
I attest the applicant worked the indicated number of hours and/or days at the work address and medical facility/private practice indicated within the
period of time identified. I also attest that the applicant was not employed at this work address prior to July 1, 2011.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for Canada Student Loan Forgiveness for Family (Government of Canada)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document