Response

Office of the State Treasurer
Student Loan Ombudsman Program
Grant Sawyer Building
555 E. Washington Ave, Ste 5200
Las Vegas, NV 89101
(702) 486-3384

Client Intake Form

Contact Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Zip

Phone

Preferred method of contact

Reason for Inquiry

What is the desired outcome for your inquiry?

What type of loan do you have?

Are you the Borrower or Co-borrower?

Who is your student loan lender?

Approximately how much do you owe?

What is your current interest rate?

Relationship to borrower:

What is the highest level of education you have completed?

What is your current employment status?

What is your household size?

What is your household income?

Demographic Information

How do you identify?

Male

Female

Prefer not to stay

What are your preferred pronouns?

She, Her, Hers

He, Him, His

Other

How would you describe yourself?

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Prefer not to answer

Are you Hispanic, LatinX, or of Spanish origin?

Yes

Prefer not to say

High School Name

High School Graduation Year

Are you the

Parent

Student

Other

Have you graduated from college?

Yes

Prefer not to stay

Are you a first generation college student?

Yes

Prefer not to stay

Copy of your most recent Student Loan statement

Upload FileNo file chosen

Copy of loan agreement

Upload FileNo file chosen

Student loan default of delinquency notices (if applicable)

Upload FileNo file chosen

NV state issued ID (to match the name of the borrower or co-borrower)

Upload FileNo file chosen

Last Year's tax return (if applicable)

Upload FileNo file chosen

Any additional documentation related to your situtation

Upload FileNo file chosen

By signing this form, you acknowledge that any information you submit on this form may become public record subject to NRS Chapter 239.

By signing this form, you acknowledge that you are granting the Office permission to use your submitted information to make inquiries into your records on your behalf to attempt to facilitate the resolution of your concern. You further acknowledge that the Office cannot act as your legal counsel, and the Office disclaims any and all liability in relation to the Office's attempts to assist you as an ombudsman

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