Request For Deferment
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1FEDERAL PERKINS, NDSL, NSL, HPSL, & LDS
Request for Deferment
PART I – TO BE COMPLETED BY THE BORROWER (COMPLETE IN INK)
Name:
Social Security #:
16 Digit Account Number(s):
Street Address:
Birthdate:
City:
State:
Zip Code:
PLEASE CHECK THIS BOX IF NEW ADDRESS
Home Phone #:
Work Phone #:
Driver’s License # and State:
Lending Institution:
Date Left Lending Institution:
E-mail Address:
DEFERMENT
BEGINNING
ENDING
(mm/dd/yy):
(mm/dd/yy):
This is to certify that I am or was (check one only):
Altered dates will not be accepted
(Please refer to your promissory note for specific eligibility requirements.)
FEDERAL PERKINS, PERKINS OR NDSL
K at least a half-time student.
K in the National Oceanic/Atmospheric Administration
K serving an internship or residency.
K in a Graduate Fellowship Study
Type of program:
K a mother entering the workforce
_________________________________________
K enrolled in a Rehabilitation Training Program
K a Peace Corps, VISTA or ACTION volunteer
K an officer in the US Public Health Service
K pre-cancellation services. Type:
K a full-time volunteer in a tax-exempt organization
K unable to work or attend school due to parental leave
_______________________________
K a member of the US Armed Forces on active duty
K active duty member of the US Armed Forces, Reserves, or National Guard in a war, military operation, or National Emergency
(loans on or after July 1, 2001 only)
NOTE: IF YOU OR YOUR SPOUSE IS TEMPORARILY TOTALLY DISABLED,YOU ARE SUPPORTING A DISABLED DEPENDENT, OR YOU ARE IN NEED OF A DEFERMENT/FORBEARANCE
FOR FINANCIAL OR UNEMPLOYMENT REASONS, PLEASE CONTACT ACS AT THE ADDRESS LISTED BELOW TO OBTAIN FURTHER INFORMATION.
HEALTH PROFESSIONS STUDENT LOANS, & LDS
NURSING STUDENT LOANS
K in a nursing program K half-time K full-time leading to
K pursuing a full-time course of study towards a degree in health
K serving an internship or residency required prior to
K baccalaureate K equivalent K graduate K R N
professions at any school of medicine, osteopathy, dentistry,
professional practice. Type of program:
____________________________
pharmacy, podiatry, optometry, or veterinary medicine
K associate degree
K a Peace Corps volunteer
K receiving full-time advanced professional training in the field for
K on full-time active duty in a uniformed service.
K on full-time active duty in a uniformed service.
Branch of service:
which the loan was received
Branch of service:
_____________________________________________________________
_______________________________________
K an officer in the US Public Health Service Commissioned Corps.
K a Peace Corps volunteer.
K participating in a fellowship training program. (for loans made
K advanced professional training.
after 10/22/85 only)
THIS FORM IS INVALID WITHOUT: BORROWER’S SIGNATURE, ACCOUNT NUMBER, BEGINNING AND ENDING DATES, AND COMPLETE CERTIFICATION. I HEREBY
CLAIM THAT THE ABOVE INFORMATION IS TRUE. I AGREE TO NOTIFY THE LENDING INSTITUTION IMMEDIATELY UPON TERMINATION OF MY CLAIMED STATUS.
X
Borrower’s Signature
Date
PART II – TO BE COMPLETED BY CERTIFYING OFFICIAL OR REGISTRAR
(NOTARY PUBLIC CERTIFICATION NOT ACCEPTABLE)
I certify that the information stated above is correct.
X
Signature of Authorizing Official
Title
Date
#
OPEID
Deferment
Official Stamp
Dates:
(MM/DD/YY)
or Seal
Name and Address of Authorizing Organization
STATUS:
If no stamp or seal is
K Full-time
FROM:
available, please provide
K At least half-time
letterhead certification.
K Less than half-time
TO:
ACS INC. – EDUCATION SERVICES
PHONE NUMBER:(
)
CAMPUS PRODUCTS AND SERVICES
RETURN FORM TO:
P.O. BOX 7060 • UTICA, NY 13504-7060
PART III – FOR OFFICE USE ONLY
K Approved
K Disapproved
Reason: _________________________________________
Inst & Dash #
Def Type
Dates of Def
Int Rev
NPD
Past Due Amt
Period Due
Pre-Canc/Def End Date
PROCESSED BY:
TITLE:
DATE:
DPS-W-10-26-06
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