Grant Information

JRJ Loan Repayment Program Pre-Application Form 2012

All Entry Fields are 'Required' *

Legal Name:*

Home Address:*

Email:*

Mailto:
Text (optional):

Job Title:*

How Many Years Have You Been Employed as a Public Defender or District Attorney?*

Employing County:*

Are You a Full Time Employee?*

Yes

Have you received JRJ assistance previously*

Yes

Instructions for Completing the Income and Loan Sections:

Income:

Line 1: Select the source of your 2011 Federal Taxable Income from the appropriate line in your 2011 Federal Tax Return

Line 2: Select your County of Residence from the COLI Drop Down Menu.

Loans:

Line 3: Enter the Total Principal Balances as of December 31, 2011 for all eligible loans.

Income:

Line 1:*

Select the Source of Your 2011 Federal Taxable Income, Then Enter the Amount Below.

Federal Taxable Income Amount*

Line 2:*

County of Residence Cost of Living Index (COLI)

Loans:

Line 3:*

Total of ALL Eligible Loan Balances.

See List of 'Eligible Loans'

Please be sure to double-check your information. Your application will be submitted by clicking on the 'SAVE' button.