Section 590.APPENDIX C   Sample Contract for Monetary Repayment of Scholarship Obligation

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

FAMILY PRACTICE RESIDENCY ACT

SCHOLARSHIP FOR MEDICAL STUDENTS

R E P A Y M E N T    C O N T R A C T

The Illinois Department of Public Health (Department) and ____________________ (Contractor) hereby agree as follows:

1)         Item ________ of the Contract signed by Department and Contractor on ____________________ allows a recipient of a medical student scholarship awarded through the Family Practice Residency Act to repay funds awarded; including a liquidated damages payment, rather than practice medicine in an underserved area of the State. A copy of the Contract is attached and shall become a part of this Contract.

2)         The Contractor has elected to repay required funds in lieu of completing the practice commitment.

3)         The Contractor received $_____________ in academic year 19___-19___; $__________ in academic year 19___-19___; $__________ in academic year 19___-19___; $_____________ in academic year 19___-19___; totaling $_____________. Copies of State of Illinois documents verifying award amounts are attached and shall become a part of this Contract.

4)         The Family Practice Residency Act required a sum equal to three times the amount of the annual scholarship grant for each year the Contractor fails to fulfill the obligation in an underserved area.

5)         The total amount due the Illinois Department of Public Health is $__________. _________ monthly installments of $__________ are to be paid to the Department pursuant to Item ______ of the Contract. The first payment is due  ___________________________.

6)         The repayment checks are to be made payable to "Illinois Department of Public Health" and mailed to Illinois Department of Public Health, Division of Financial Services, 535 West Jefferson Street, Springfield, Illinois 62761, Attention:  Manager – Fiscal Control. The payments are to be postmarked on or before the first day of the month.

7)         In the  event the Contractor fails to pay the Department any required installment, the Department may file suit to collect all sums and future sums due and owing under this Contract or may refer the matter to a collection agency.

8)         Contractor shall pay all costs of suit, including attorney fees, and all collection costs in the event the Department shall prevail in suit for money damages against Contractor pursuant to this Contract.

9)         If Contractor becomes disabled the terms and conditions of this Contract shall be suspended until such time as Contractor is able to resume repayment.

10)         Contractor shall inform the Department, in writing, within 14 days of any change of address or any disability affecting obligations of this Contract.

11)         This Contract shall be governed in all respects by the laws of the State of Illinois.

12)         This Contract may not be amended without prior written approval of both Department and Contractor.

13)         This Contract may not be sold, assigned or transferred in any manner.

14)         The Department and Contractor understand and agree that this Contract constitutes the total agreement between them and that no promises, terms or conditions not recited, incorporated, or referenced herein shall be binding upon either Department or Contractor.

15)         In the event the Family Practice Residency Act is amended while this Contract is in effect, this Contract shall be amended automatically to incorporate such amendments to such Law.  However, obligations of contractor shall not be increased.

16)         In the event any portion of this Contract is held invalid by any court of competent jurisdiction, the remaining terms and conditions shall remain in full force and effect.

17)         This Contract shall remain in full force and effect until Contractor has repaid all funds to the Department pursuant to the terms of this Contract.

18)         Under penalties of perjury, I certify that the social security number shown below is my correct Federal Taxpayer Identification Number.

Executed this____________ day of ____________________, 19 __.