Student Loan Deferment Form - University Of Maryland printable pdf download

Student Loan Deferment Form

PART 1

To Be Completed by the Borrower

(Please Print)

Full Name: _______________________________________________________________________________________

SSN last 4: XXX-XX-__________________ Email: ________________________________________________________

Mailing Address: __________________________________________________________________________________

Home Phone: ___________________ Cell Phone: ______________________ Work Phone: _____________________

PART 1.2

Period of Request

Missing information & altered dates will not be accepted

Beginning Date: (mm/dd/yy)

Ending Date: (mm/dd/yy)

Anticipated Separation Date: (mm/dd/yy)

____/____/____

PART 1.3

Reason for Request

This is to certify that I am or was: (check all that apply)

Federal Perkins, Perkins or NDSL:

Health Professions: UM-Institutional:

Nursing:

A Peace Corps, VISTA or ACTION volunteer

A Peace Corps volunteer

In the National Oceanic/Atmospheric

On full-time active duty in a uniform service

Active duty in the uniformed services

Administration

Participating in a fellowship training program

Full-time or half-time enrollment in a

An officer in the US Public Health Services

Serving an internship or residency

collegiate nursing program leading to a

An officer in the US Public Health Service

baccalaureate degree/graduate

A full-time volunteer in a tax exempt

Commissioned Corps

degree in nursing

organization

Receiving full-time advanced training in the field

Pursing advanced professional training

for which the loan was received

in nursing, or training to become a

Pursing a full-time course of study towards a

nurse anesthetist

degree in a health profession school within the

applicable grace period

PART 1.4

Declaration

I hereby claim that the above information is true and accurate. I agree to notify University of Maryland immediately upon termination of or change

in my claiming status. I further declare that if, for any reason, I am unable to complete a year of service for which I have requested deferment

benefits, I will begin repayment of my loan.

Borrower’s Signature: _______________________________________________________ Date: _________________________________________

Part 2

To Be Completed by Certifying Official -

**school certification section requires the Federal School Code

I certify that the information stated above is correct: ______________________________________________ Date: _________________________

(Authorizing Signature)

Printed Name: _____________________________________________________ **Federal School Code: __________________________________

Institution Name: _______________________________________________________________________

Official Seal or Stamp

Address: ______________________________________________________________________________

Telephone: ____________________________________________________________________________

*IF SEAL OR STAMP IS UNAVAILABLE, PLEASE PROVIDE LETTERHEAD CERTIFICATION*

University of Maryland-Baltimore (X7)

Return Forms To:

c/o Heartland ECSI

P.O. Box 1278

If you have any questions, please visit us at https://heartland.ecsi.net

or call us toll-free at 888.549.3274.

Wexford, PA 15090

FOR ECSI USE ONLY

Approved _____ Disapproved _____ Official Name ______________________________________ Date _____________

Student Loan Deferment Form - University Of Maryland

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