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Name:
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_______________________________________________________
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Account Number(s):
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________________________________________________
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Address:
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_______________________________________________________
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________________________________________________
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_______________________________________________________
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________________________________________________
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Telephone: (home)
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________________________________________________________
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Date of Birth:
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________________________________________________
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(work)
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________________________________________________________
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Social Security Number:
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________________________________________________
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I request deferment of my student loan(s) payments‚
beginning______________and ending_______________. I meet the
qualification(s) I have checked below‚ and I have attached
the required documentation. I understand that the maximum
benefit is three years‚ which will be granted to me in
periods of not more than one year at a time. Read this entire
form before you fill it out. If you do not qualify for any
of these benefits‚ please send a request for forbearance.
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1.
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___
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Prolonged illness‚ starting ____________and ending_____________
. Attach explanation of how your health affects your
ability to pay this loan(s). Provide physician statement
of diagnosis‚ and submit with this application.
Complete the Income & Expense Summary on reverse side.
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2.
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___
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Unemployed since ________________. Provide documentation
such as proof that you are collecting unemployment benefits
and‚ if you are still unemployed‚ that you
are actively seeking employment (attach a list of firms
where you have applied for employment‚ including
the firms’ name and address‚ and the name
and telephone number of a person to contact for verification);
or .
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___
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working part time and unable to find full–time
employment (full time= 30 hours per week for three consecutive
months). I have not worked full time since ________________.
To receive deferment of payments under this provision‚
provide one of the following information:
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_______I registered with the following public or private
employment agency (does not include school placement
offices or temporary employment agencies):
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Name of agency: _________________________________________________
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Address: _______________________________________
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Contact: _______________________________________________________
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_____________________________
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Telephone:_____________________________________________________
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_____________________________
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___
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I have not registered with an employment agency (attach
explanation).
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___
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In the last six months‚ I have attempted to secure
employment. Attach a list of firms where you have applied
for employment‚ including the firms’ name
and address‚ and the name and telephone number
of a person to contact for verification.
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3.
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___
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I have been granted an Economic Hardship Deferment
on my other federal loan(s) for the period starting______________
and ending_______________ ‚ and I request this
same deferment‚ for the same period of time‚
on my Federal Perkins Loan. I have attached documentation
of the deferment I received on my other federal loan(s).
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4.
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I receive payment under a federal or state public assistance
program‚ such as Aid to Families with Dependent
Children‚ Supplemental Security Income‚ Food
Stamps‚ or state general public assistance. I have
attached documentation that I am receiving these benefits.
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5.
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I work full time (30 or more hours per week)‚
and
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________my Total Monthly Gross Income (TMGI) does not
exceed the federal minimum wage‚ or 100% of the
poverty line for a family of two;) or
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________ my TMGI is not greater than twice the federal
minimum wage or the poverty line for a family of two’
and when I subtract the amount of payments I must make
on all my federal education loans from my TMGI‚
the result is not more than the greater of the federal
minimum wage or the poverty line for a family of two;
or
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_______ the amount of payments I must make on all my
federal education loans2 is at least 20% my TMGI‚
and the difference between my TMGI and the amount of
payments I must make on my federal education loans is
less than 220% of the minimum wage or the poverty line‚
whichever is greater. To determine your eligibility
for deferment of payments under No. 5‚ provide
the following:
Total monthly gross income (the gross amount you receive
from employment and other sources before taxes and other
deductions): $____________________________ (attach copy
of last tax return‚ and most recent pay statement).
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Total monthly payments on federal education loans (list
each federal loan lender (school/financial institution)‚
type of federal education loan (Perkins/NDSL‚ Stafford‚
Direct‚ Consolidation‚ Health Professions/Nursing‚
etc.)‚ the amount you borrowed‚ and the amount
of your monthly payment for each one. Attach copy of
monthly bill for each loan.
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Lender.
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Type of Loan:
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Amount Borrowed
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Monthly Payment
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1.______________________________
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_________________________________
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$
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$
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2.______________________________
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_________________________________
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$
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$
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3.______________________________
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_________________________________
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$
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$
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4.______________________________
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_________________________________
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$
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$
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5.______________________________
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_________________________________
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$
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$
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Signature:______________________________________________________________Date:_________________________________________________
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- The Poverty Line for a family of two is determined
each year by the Federal Government and published
in the Federal Register. Effective February 24‚
1998‚ the Poverty Line income was 313‚570
for Alaska‚ $12‚480 for Hawaii‚ and
$10‚850 for all other states and the District
of Columbia
- Total monthly payments‚ adjusted. if necessary‚
to reflect the maximum ten–year repayment period‚
will be calculated based on the information I provide
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