The debt will be referred to a debt collection agency and the Illinois Attorney General’s Office. Any loan repayment debt past due for three months shall be referred to a debt agency. If the debt collection agency is unsuccessful in receiving payment in full, the debt will be referred to the Illinois Attorney General’s Office for enforced collection. State payments due to the grantee (e.g. state income tax refund) may be offset by the Illinois Department of Revenue to repay a delinquent loan repayment debt. HOW IS APPLICATION MADE? Applications are available on the IDPH website at . A separate application for the site is also available on the website. Completed applications should be sent to: Center for Rural Health Illinois Department of Public Health 535 W. Jefferson St. Springfield, IL 62761 SITE CERTIFICATION I certify that the applicant(s) will practice full time at public or non-profit private entities providing primary health services in a federally designated health professional shortage area (HPSA). In addition, I certify that the organization shall provide 50 percent of the loan repayments to support the applicant(s) who agreed to practice in the facility for one of the following: TWO-YEAR SERVICE COMMITMENT Yes No Site Contribution: Up to $12,500/ year for two years THREE-YEAR SERVICE COMMITMENT Yes No Site Contribution: Up to $10,000/ year for the third year FOUR-YEAR SERVICE COMMITMENT Yes No
The debt will be referred to a debt collection agency and the Illinois Attorney General’s Office. Any loan repayment debt past due for three months shall be referred to a debt agency. If the debt collection agency is unsuccessful in receiving payment in full, the debt will be referred to the Illinois Attorney General’s Office for enforced collection. State payments due to the grantee (e.g. state income tax refund) may be offset by the Illinois Department of Revenue to repay a delinquent loan repayment debt. HOW IS APPLICATION MADE? Applications are available on the IDPH website at . A separate application for the site is also available on the website. Completed applications should be sent to: Center for Rural Health Illinois Department of Public Health 535 W. Jefferson St. Springfield, IL 62761 SITE CERTIFICATION I certify that the applicant(s) will practice full time at public or non-profit private entities providing primary health services in a federally designated health professional shortage area (HPSA). In addition, I certify that the organization shall provide 50 percent of the loan repayments to support the applicant(s) who agreed to practice in the facility for one of the following: TWO-YEAR SERVICE COMMITMENT Yes No Site Contribution: Up to $12,500/ year for two years THREE-YEAR SERVICE COMMITMENT Yes No Site Contribution: Up to $10,000/ year for the third year FOUR-YEAR SERVICE COMMITMENT Yes No
slrp-provider-application-02272015-form-fillable-v3-042616.docx