Loan Assistance Program Application
I hereby certify that I abide by Columbia Business School’s Honor Code, have not been
subject to any disciplinary action (academic or professional) in the last 10 years, and all
information provided with this application is truthful. I am aware that any
misrepresentation of facts in any part of this application will justify the denial or
revocation of Loan Assistance funds.
Signature ___________________________________ Date _________________
I.
Personal information
Name:
Social Security #:
Local Address:
Phone:
Permanent Address:
Phone:
Email:
Graduation Year:
Degree(s):
II.
Employment information
Employer:
Dept/Division:
Address:
Office Phone:
Fax:
Job Title:
Supervisor Name/Title:
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References
Please provide names and contact information for two people who can provide additional
information about you.
Name: _________________________________________________________________
Address: ________________________________________________________________
Phone: ___________________________ Email: _______________________________
Name: __________________________________________________________________
Address: ________________________________________________________________
Phone: ____________________________ Email: _______________________________
III.
Needs assessment
Needs-based loans for Columbia Business School (DO NOT include other educational debt):
Lender &
Type *
Account Number
Loan
Amount
Total: $
Current
Balance
Interest
Rate
Repayment
Term
$
Monthly
Payment
$
* Federal vs Private.
Other educational debt (non-Columbia Business School):
Lender
Account Number
Loan
Amount
Total: $
Marital Status:
Single ❒
Current
Balance
$
Married ❒
Interest
Rate
Repayment
Term
Monthly
Payment
$
Other:
Income
Applicant’s annual salary (DO NOT prorate this number):
Applicant’s other annual income:
Bonus:
Dividends:
Interest:
Other:
Total Income:
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Assets
If married, please include joint assets in your calculations.
Cash, Savings, Checking Accounts
Stocks, Bonds, CDs, Other Investments
Trust Funds
Home Equity
Other Properties
Other Assets:
Please describe:
Total Assets:
V.
Additional required materials
In addition to the information provided above, please enclose the following documentation with
your application:
A personal statement, not exceeding 2,500 words, addressing the following
questions:
i. What is the mission of the organization at which you are employed?
ii. What is the nature of your position? Describe your primary responsibilities
and explain how they fit with the goals and mission of the organization.
iii. What are your long-term professional goals and how does this position fit
with these goals?
iv. How do you hope to further the goals and mission of the organization?
Resume;
Verification of outstanding loan debt from lenders and servicers, including a
summary statement of total outstanding loan balances, required monthly
repayment, and history of previous loan payments;
A letter from your employer/supervisor indicating the starting date of
employment, hours worked per week, the nature of your position, and your annual
salary, including bonus, commission or other financial remuneration;
If you have not received loan assistance in the past with this employer:
information about the organization, its mission and program activities (e.g.,
annual report, brochure);
Proof of your employer’s 501(c)(3) tax exempt status, or equivalent tax exempt
status outside of the United States. The document should specify the type of tax
exempt status and not merely state that the organization is tax exempt. Individuals
working for federal, state or local governments do not need to submit proof of tax
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exempt status; OR
For other organizations: proof and date of incorporation; statement of which
category (5 -7) your employer is in; detailed evidence of integration of
social/environmental purpose in core strategies and operations of the business
(and any other proof the shows your organization is eligible); and summary
financial statements if older than 5 years, or evidence of investment or funding
attracted to date for ventures less than 5 years old.
A copy of your most recent U.S. Federal Tax Return (1040), including all
schedules and W-2 forms, and/or equivalent tax return documents filed outside of
the United States. For foreign tax statements, include copies of the most recent tax
statements from any and all countries in which you filed, as well as a written
statement indicating all countries with which you filed tax return documents. If
you filed a U.S. 1040 NR form please provide a copy of that as well. If you did
not file a tax statement in any country, please provide a written explanation; and
A written statement showing foreign currency conversion rates to U.S. dollars at
the time of application for any information provided in the documentation above,
if relevant.
A consolidation disclosure statement provided by the lender, showing the
underlying loans, if you refinanced your loans.
Other Sources of Loan Assistance:
Are you receiving assistance in your repayments from any other organizations?
No ❒
Yes ❒ (Please provide details and amounts.)
Past Loan Assistance Recipients (only):
If you received loan assistance last year, funds were disbursed to you via direct deposit. Have
your bank account details changed? No ❒
IV.
Yes ❒ (we will contact you for details.)
Optional information
If there are any extenuating circumstances that you believe make you a strong candidate for
the Loan Assistance Program, please discuss them here. Feel free to attach a separate sheet if
necessary.
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VI.
Instructions to Submit Application
Please mail the application and supporting documents no later than October 15th. The
documents should be sent to:
The Tamer Center for Social Enterprise
The Loan Assistance Program
Columbia Business School
3022 Broadway, 203 Uris Hall
New York, NY 10027
(212) 854-2176
The application must be postmarked by October 15th. Questions regarding the application
process and program guidelines should be directed to socialenterprise@gsb.columbia.edu.
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