Request For Deferment Form - Federal Perkins Loan, Nursing Student Loan, Health Professions Student Loan, Loans For Disadvantaged Students
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1REQUEST FOR DEFERMENT - FEDERAL PERKINS LOAN, NURSING STUDENT LOAN, HEALTH PROFESSIONS STUDENT
LOAN, LOANS FOR DISADVANTAGED STUDENTS
(Please complete in ink)
Name
Lending Institution
16 digit Account Number
Address
Home phone: (
)
Dates Requested (mm/dd/yy):
Return Form to:
Work Phone: (
)
Begin Date: _______________
Cell Phone:
(
)
ACS Education Services
End Date: ________________
Campus Products and Services
P.O. Box 7060
Email:
Utica, NY 13504-7060
Driver’s License #/State
Birthdate:
You may qualify for one of the following deferment benefits, even if they are not specifically listed in your original promissory
note. Please visit our website for further information or clarification:
Perkins Deferment Conditions:
Health Professions Deferment Conditions:
At least half-time student
Pursuing a full-time course of study toward a degree in
Enrolled in a Rehabilitation Training Program
health professions
Graduate Fellowship
Internship/Residency prior to professional practice
Unemployment
Program: _____________________
Military Service (combat)
Fellowship Training Program
Branch of Service:___________________________
Advanced Professional Training
Military Operations
Peace Corps Volunteer
Military Demobilization
Officer in the US Public Health Services Commissioned
Performing Service eligible for Cancellation
Corps
Other: ______________________________ (Only for loans
Military Service (active duty):
received prior to July 1, 1993)
Branch of Service ________________________
Nursing Deferment Conditions:
Name of School or Employing Agency
At least half-time in a Nursing Program
___________________________________________________
Advanced Professional Training
Peace Corp/Volunteer
___________________________________________________
Military Service (active duty):
City
State
Zip
Branch of Service ________________________
I declare that the information shown above is true and accurate. I further declare that I will notify my lender immediately upon
any change in my status. If I am unable to complete the year for which I have applied for deferment, I will begin loan
repayment immediately.
Borrower Signature: ______________________________________________________ Date: ____________________________
CERTIFICATION of DEFERMENT STATUS
Official Stamp or Seal
Name of School/Unit/Employer: ________________________________________
Address: ___________________________________________________________
(If no stamp or seal is available,
___________________________________________________________
please provide supporting
___________________________________________________________
documentation on official
Phone: (
)_________________________________________________________
letterhead)
I certify that the information stated above is correct.
Status :
____ Full Time
OPEID#
INTERNAL USE ONLY:
____ At least Half-Time
____ Less than Half-Time
_________________________
Deferment Approved/Processed
Dates - From:____________
To:_____________
Date Processed: ______________
Signature of Certifying Official: ________________________________________
Processor: _________________
Title of Certifying Official: ____________________________________________
Date: _______________________
Ver112009
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