Student Loan Repayment Application ROZ Student Loan Repayment Application 2019 A KDC representative will review your information, and contact you if they have any questions and when funding is available from your sponsor. Please have the following documents ready for upload prior to starting the application: 1) Valid Personal Identification (Driver's License, State ID, ETC.) 2) Proof of your three (3) previous addresses prior to relocating to the ROZ County 3) Proof of ROZ County residency 4) Transcript with degree date 5) Proof of student loan balance with distribution dates I understand that I am applying for a high demand program; if applying for County Sponsorship I understand that if the County does not have funding I may not be contacted about my application for many years.*TrueFalseCounties with no funding available as of 1/1/2019. These Counties are Employer Sponsor only counties you will not be contacted if you apply for county sponsorship in one of these counties. What kind of Sponsorship are you applying for?*County SponsorCity SponsorEmployer SponsorFoundation SponsorSelect Employer or County. - Who will be partnering with the State to fund your ROZ benefit. Which ROZ county are you applying for?*AllenAndersonBarberBourbonBrownChautauquaCherokeeCheyenneClarkClayCloudCoffeyComancheDecaturEdwardsElkEllsworthGoveGrahamGrantGrayGreeleyGreenwoodHamiltonHarperHaskellHodgemanJacksonJewellKearnyKingmanKiowaLaneLincolnLinnLoganMarionMarshallMeadeMitchellMontgomeryMorrisMortonNemahaNeoshoNessNortonOsborneOttawaPawneePhillipsPrattRawlinsRepublicRiceRooksRushRussellScottSheridanShermanSmithStaffordStantonStevensSumnerThomasTregoWabunseeWallaceWashingtonWichitaWilsonWoodsonROZ Sponsor Name*How important were the ROZ incentives to your decision to move to a ROZ county?*Not ImportantNot very importantImportantVery ImportantMost important reason for movingHave you or a member of your family ever lived in Kansas?NoTWhere?List all Counties Please provide details regarding your important needs as you transition to a ROZ county, such as housing, job, access to healthcare, quality of schools, recreational activities, hobby/organizations, etc.What attracted you to this particular county?100 character limitContact InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Previous NamesEmail* Cell Phone*Will you accept text notifications?*YesNoSecondary Phone NumberWhen did you first establish domicile in the ROZ County?* This is the day you move to the county not necessarily the day you moved to your current address. Current Address in ROZ CountyROZ Physical Address*ROZ Domicile AddressROZ County*ROZ PO Box20 Character LimitROZ City*20 Character LimitROZ State*AKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYROZ Zip*Previous Residence Please provide the following details on each of your primary residences within the 10 years immediately prior to establishing your primary residence within a ROZ county, starting with your most recent residence in the section labeled "Address 1." Please provide detailed information on your previous residency prior to moving to the ROZ county. You will be required to show proof of previous residency. Please review required documents at www.kansascommerce.gov/programs-services/rural-opportunity-zones/When did you establish this address as your primary residence?* When did you vacate this address?* Previous Address 1* Street Address City ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Previous State 1AKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPrevious County 1*Previous Address 2The address you were at before the address listed in the Previous Residence sectionDate Established Residence 2 Date Vacated Residence 2 Previous Address 2 Street Address City ZIP Code Previous State 2AKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPrevious County 2Previous Address 3the address you were at before the address listed in the Previous Address 2 sectionDate Established Residence 3 Date Vacated Residence 3 Previous Address 3 Street Address City ZIP Code Previous State 3AKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYPrevious County 3Income InformationWho is your employer?*If not employer list: Home Maker, Student, Searching, Other (If Other explain)Please enter your expected annual household income.*25 character limitWhich of the following most accurately describes your profession or planned profession?*AgricultureAccountingEducationEngineerFinanceGovernmentHealthcareLegalManufacturingRetailOtherPlease list professional title*100 character limit. Are you interested in starting or purchasing a business?TrueFalseEducation InformationUniversity College or Trade School Attended*150 character limitDegree Type*Select OneAssociatesBachelorsMastersDoctorateTechnical DegreeOtherList highest degree prior to moving to the ROZ County.Date of Degree* Date of highest degree prior to moving to the ROZ County.Please select the academic discipline in which you earned your degree.*AgricultureArtsBusinessCulinaryEducationEngineeringHumanitiesLawMedicalNursingSciencesVocationalOtherAcademic discipline description*100 character limitStudent Loan InformationDo you currently have an outstanding student loan balance?*TrueFalseTotal balance of outstanding student loans*You will be required to show proof of Student loan balance and distribution dates. Date of last loan distribution* Name of lending institutions*please name all lending institutions using a ";" to separate.Personal Identification* Drop files here or Driver's License, State ID, etc.Proof for ROZ Residency* Drop files here or Lease, Mortgage, Utility Bills, etcProof of previous address/es for 10 years* Drop files here or Lease, Mortgage, Utility Bill, etc.Transcripts* Drop files here or A copy of your transcripts with degree dateProof of Student Loan balance* Drop files here or This must include your name and the distribution dates of the loan/s. Other InformationWhere did you hear about the Rural Opportunity Zone program?*BankBillboard/SignageChamber of CommerceChurchCity CouncilCity WebsiteColleagueCollege AdvisorCollege WebsiteCounty CommissionCounty Extension OfficeCounty WebsiteEconomic Development OfficeEmployer/Co-WorkerFamily MemberFlyer/PamphletFriendGovernor/State OfficeInternet AdvertisementJob FairKS Dept. of Commerce/website/staff memberLawyer/AttorneyLegislatorMail RecipientNewsletterNewspaperPotential Employer/InterviewRadio BroadcastRealtorROZ ParticipantROZ WebsiteSocial NetworkingState WebsiteTelevision News/AdUniversity/School NewsWeb Search/ResearchWorkforce Center/Employment ServiceOther:Would you be willing to speak to the media about your experience with the Rural Opportunity Zone program?TrueFalseHave you lived out side of Kansas for the previous 5 years?TrueFalseDid you make less than $10,000 a year in Kansas source income during those 5 years?TrueFalseYou may qualify for a 5 year Kansas State income tax waiver! Please follow the link to the Kansas Department of Revenue's ROZ Qualification page after submitting your application. https://www.ksrevenue.org/prtaxcredits-roz.html Please Note: If you choose the Submit and Print option below, you must be sure to click the Continue button at the bottom of the form once you've printed your copy in order for your application to be submitted. Note: Kansas Dept. of Commerce may request additional information if deemed necessary to verify eligible loan balances and establish a payment process.CAPTCHAList Section BreakCommentsThis field is for validation purposes and should be left unchanged.