University of Georgia Law : Application for Annual Grant: Grant Year 2013

Application for Annual Grant: Grant Year 2013

TO APPLY: Fill out this form and submit it by midnight on December 31, 2012. If you have any questions, please contact

Beth Shackleford at 706-542-5156.

Your Last Name: *

Your First Name: *

Your Middle Name: *

Your Address: *

Home Phone Number: *

Work Phone Number: *

Home E-Mail: *

Work E-Mail: *

Graduating Year: *

Your Employer: *

Please provide your employer's information in the field of public interest law, including Name, Phone Number and Address.

The Work You Expect To Do For Your Employer: *

Please describe briefly the nature of the work you expect to do for your employer in the field of public interest law.

Total Qualified Debt You Will Owe at Beginning of Grant Year: * $

Amount of Qualified Debt You Must Repay During Grant Year: * $

Your Other Debt and Household Debt:

If you or a member of your household will owe substantial debt, other than qualified debt, during the grant year, list below the nature of the debt and the amount that must be repaid during the grant year. Please include: 1. Nature of Debt, 2. Total Amount, 3. Amount that must be repaid during the grant year for each item you list.

Your Expected Gross Income During Grant Year: * $

Your Spouse's Expected Gross Income During Grant Year: $

Other Household Income:

If your household will have income other than your income and your spouse's income during the grant year, list the income below. Please include: 1. Nature of household income, 2. Amount of household income for each item listed.

Loan Repayment Assistance From Other Sources:

If you are receiving loan repayment grants or any other sort of loan repayment assistance from your employer or any other sources, please indicate those below. Please include: 1. Source of Loan Repayment Assistance, 2. Amount of Assistane (Annually) for each item listed.

Your Assets and Household Assets (check one): *

Less than $5,000

$5,000 - $25,000

$25,000 - $50,000

More than $50,000

Select the option below that most accurately reflects the total value of assets that you and members of your household will own during the grant year, including home equity, bank accounts, securities, etc.

Household Dependents:

If you will be responsible during the grant year for the living expenses of persons in your household other than yourself, enter the number of such persons here.

Your Long-Term Career Goals: *

Describe briefly the connection between your expected employment in the field of public interest law and your long-term career goals.

Your Prior Commitment to Public Service: *

Describe briefly any activities that demonstrate your prior commitment to public service.

Your Law School Career: *

Describe briefly any features of your law school career that you believe should be considered in evaluating your application, including academic performance, courses taken, co-curricular activities, extracurricular activities, etc.

Your Career Plans (check one): *

I intend to remain employed in the field of public interest law throughout my career.

I intend to remain employed in the field of public interest law for at least the next five years.

I intend to remain employed in the field of public interest law for at least the next two years.

Select the statement below that most accurately reflects your current career plans.

I swear or affirm that, to the best of my knowledge, the statements I have made in this application are true.: *

I swear or affirm that, I have read and understand the Charter of the Loan Repayment Assistance Program of the University of Georgia School of Law and agree to abide by the terms of the Charter. : *

Charter of the Loan Repayment Assistance Program of the University of Georgia School of Law

Your Signature: *

Please sign this form using your initials.

The Date: *

Please provide today's date.

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Application for Annual Grant: Grant Year 2013