Profile Update Form - Give Back, Get Back Program Application

Profile Update Form - Give Back, Get Back Program Application

Please submit your information below if you need to update HIPHI on change(s) to personal information provided on your application to the Give Back, Get Back Program.
Changes to report to HIPHI include:
- Change of Name
- Change of Address due to relocation outside of Hawaiʻi
- Change in Employment
- Change of Lender Company
Failure to update HIPHI in a timely manner may result in a delay of your award payment or disqualification from the Give Back, Get Back program.

To reach out for any questions or inquiries, please contact HIPHI at studentloan@hiphi.org or call us at (808) 591-6508 x 28 during office hours.

Hours of Operations: Monday - Friday, 8:30 a.m. - 4:30 p.m.
Please select which change(s) of personal information you are reporting on:

NameAddress/relocation outside of HawaiʻiEmploymentLender Company
Original Name (First Name, Middle, Last):

First NameMiddle NameLast Name
*New* Name (First Name, Middle, Last):

First NameMiddle NameLast Name
Date of Name Change

MonthDayYear
Date
Upload a copy of your new government-issued identification with your new last name here. A temporary Driver's license and/or passport are accepted.

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Original Hawaiʻi Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*New* Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Relocation

MonthDayYear
Date
Please upload proof of new residency. Acceptable documentation include a utility bill, rental agreement, or mortgage statement.

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Please complete the Give Back, Get Back Employment Verification Form with your new employment information and attach it below. In order to maintain eligibility to receive an award of the Give Back, Get Back Program, your new employment site MUST be an approved employment site. Examples are:
- Government or non-government entities
- Clinics/Community Health Centers (funding for population-level staff, not direct patient care)
- Environmental Agencies
- Health Insurance Companies (roles such as Patient Navigator, Health Educator, Community Health Worker/Community Health Outreach Worker)
- Hospitals (funding for population-level health staff, not direct patient care)
- Human Services Providers (including faith-based organizations, food banks, transportation services)
- Laboratories
- Mental Health Organizations
- Nursing Homes
- Public health community-based organizations
- Public Safety Agencies
- State or local health departments
Upload your Updated Give Back, Get Back Employment Verification Form here. Please ensure it is signed by your current Supervisor or HR Representative.

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Please provide contact information below if the Lender Company you used to finance your education has changed. You must submit a copy of a current lender statement that MUST include the current balance, account number, and the address to which payment is submitted. Alternative documents like a loan summary and screenshot of your account showing your payment plan total are acceptable if they include all the required information.
Original Lender Name:
*New* Lender Name:
*New* Lender Address (send payments to):
Account Number:
Upload your copy (copies) of current lender statement here. Please combine your statement(s) into one file.

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Applicant Name:
Applicant Email:
example@example.com
Should be Empty: