EmailMe Form - Clergy Debt Relief

Legal Name *

First Middle Last

Legal Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Confirm Email

Eligibility *

	True	False
I am resident in the Diocese of California or San Joaquin and serving in a diocesan congregation and/or institution.
I have served in the Diocese of California or San Joaquin for at least 12 continuous months leading up to June 1 of this year.
I understand that debt relief may only be used for repayment of outstanding debt from theological education.

Fund Requirements *

	True	False
I have completed and reported all continuing education for the past year as required by my diocese.
I have engaged in regular self-directed study of at least one hour per week or 52 hours per year.

500-word Reflection on Self-Directed Study

For this and subsequent paragraph text fields, we recommend you compose your answers in a minimally formatted word processing document, saving as you go along. Then copy/paste the text of each answer into the appropriate box of this form when you are finished. This approach can help you avoid losing your work if you accidentally close this browser tab.

Site of Ministry *

Congrgation or Institution where you serve

Hire Date *

MM / YYYY

Are you serving in a full-time or part-time position? If part-time, please specify further (e.g., three-quarter time, half-time, 10 hours per week, etc.). *

When did your employment in the diocese begin? *

MM / YYYY

How many times have you been granted clergy debt relief? *

Site of Ministry Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Outstanding Student Loan Debt from Theological Education *

$ Dollars

Loan account/identification number

Name of loan servicer or other debt-holding institution *

Loan Servicer Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Current Loan Statement *

Please upload a .pdf of your most recent loan statement.

Is there anything else we need to know about your financial or employment situation? If so, please explain.

Signature *

Clear

Depending on your hardware, you may use your finger, mouse, digital pen, or a similar pointing device to sign your name. If you want to start over, select "Clear."