Federal Perkins (Ndsl) Student Loan - Request For Deferment
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1
2SECTIONS A-D MUST BE COMPLETED FULLY
This space for servicer’s use only
BORROWER MUST COMPLETE ALL AREAS OUTLINED IN RED AND/OR IN DASHES
This space for servicer’s use only
Federal Perkins (NDSL) Student Loan – Request for Deferment
Please print-This section must be filled out completely.
Name
Social Security No.
Account number(s) on billing statement
Address
Check if new address
City
State
Zip
Home Phone
Work Phone
(
)
(
)
Return to: Campus Partners
P.O. Box 2901
Email address
Cell Phone
(
)
Winston-Salem, NC 27102-2901
Fax: 336-607-2093
Institution that granted loan(s)
A. Deferment: Check one block for deferment type. (One block must be checked.)
B. Dates deferment requested
Altered dates
All loans
Federal Perkins
National Direct
National
Beginning
and
Ending
must be
disbursed
disbursed on or
disbursed on or
Direct
on or
after 7/1/87 but
after 10/1/80 but
disbursed
initialed by
DEFERMENT
NOTES
after 7/1/93
before 7/1/93
before 6/30/87
before 10/1/80
Mo. Day
Yr.
Mo. Day
Yr.
certifying official
CONDITION
At least
Form required for each
Check if you intend to enroll next semester/quarter
Half-time student
Yes
Yes
Yes
Yes
quarter/sem. after official
registration
C. Borrower signature
Rehabilitation
Yes*
Yes #*
Yes #*
Yes #*
For disabled individuals
I declare that the information above is true and accurate.
Training
I further declare that I will notify my lender or loan servicer
Graduate Fellowship
Yes*
Yes #*
Yes #*
Yes #*
Form required each year
immediately upon change in my status. I further
Must be full time
understand that if, for any reason, I am unable to
Internship/residency
No
Two years*
Two years*
No
Must be required to begin
complete the term of service for which I have requested
professional practice
deferment benefits, I will begin repayment of my loan,
Dental residency
Yes
Yes#
Yes#
No
Must be required to begin
including deferred payments, immediately.
professional practice
Signature of borrower
Inability to secure
Three
Yes #*
Yes #
Yes #
This form cannot be used for
full-time job
years
this deferment
Economic Hardship
Three
Yes #*
Yes #
Yes #
This form cannot be used for
years
this deferment
Date
Full-time volunteer,
No
Three years*
Three years*
No
On full-time active duty; entire
for tax-exempt org.
enlistment required
Internal Use Only:
Peace Corps/Action
Yes +
Three years
Three years
Three years
Entire enlistment required
Date processed
Analyst’s initials
Comment
U.S. Armed Services
If combat/
Three years
Three years
Three years
Entire enlistment/copy of
active duty
military orders required
Last 3 digits
Officer in PHS
No
Three years
Three years
No
Commissioned Corps of
Program No. SEQ No.
Public Health Service
QL
NOAAC
No
Three years*
No
No
National Oceanic & Atmos-
pheric Administration Corps
Type
Begin
End
Temporary total
No
Three years*
Three years*
No
Cannot be employed or
Mo. Year
Mo. Year
disability
attending school
borrower/spouse
Care of totally
No
Thee years*
No
No
Cannot be employed or
disabled
attending school
Last 3 digits
dependent
Program No. SEQ No.
Mother returning to
No
One year*
No
No
Preschool children
work
QL
Parental leave
No
Six months*
No
No
Pregnancy, newborn or child
adoption
Type
Begin
End
Mo. Year
Mo. Year
*Additional documentation required. Please contact servicer or see Deferment Information on our web site at
+ In anticipation of cancellation
# For periods beginning 10/07/98 or after
D. Certification of Deferment Period and Status (School or service unit)
Last 3 digits
Program No. SEQ No.
OPE Code
Note: We cannot accept a form certified more than 30 days prior to the beginning of your enrollment
period.
QL
Type
Begin
End
Name of school or service unit
Phone No.
Mo. Year
Mo. Year
Address
PO Box
Street
For Lending Institution use only:
Request disapproved
City
State
Zip
Deferment approved
I certify that this student is/was enrolled as at least a
half-time or a
full-time regular degree-seeking student (defined
in 34 CFR 600.2) for the deferment period indicated in Section B, leading to a degree in
Student status
Military service
Peace Corps
VISTA
Internship/Residency
Dental residency
Our institution is on the
Semester
Quarter
Trimester
Clock Hour system
Volunteer service
U.S. Public Health Service
NOAAC
Parental Leave
I certify that this borrower is/was serving in an internship/residency program required for professional practice in the field of
Graduate fellowship/rehabilitation training
Working mother
I certify that this borrower is/was in an approved graduate fellowship program.
This space is for institutional seal.
Temporary total disability:
If not available, provide official letter of certification.
spouse
dependent
borrower
An approved rehabilitation training program for disabled individuals.
SEAL
Date of status:
Beginning
Ending
Signature of Certifying Official (Altered dates must be initialed by Certifying Official.)
Date
Signature
Date
Title of Certifying Official
9164F (11-09)
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