Request For Deferment Form - Request For Deferment Form - Federal Perkins Loan - 2016
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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
Dates Requested (mm/dd/yy):
Return Form to:
Home phone: (
)
Work Phone: (
)
Begin Date: _______________
Cell Phone:
(
)
Conduent Education Services
End Date: ________________
Campus Products and Services
Email:
P.O. Box 7060
Driver’s License #/State
Birthdate:
Utica, NY 13504-7060
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:
Performing Service eligible for Cancellation
Pursuing a full-time course of study toward a degree in
health professions
Name of Employing Agency
Internship/Residency prior to professional practice
Program: _____________________
___________________________________________________
Fellowship Training Program
Advanced Professional Training
___________________________________________________
Interruption of Studies/Leave of Absence
City
State
Zip
Peace Corps Volunteer
Officer in the US Public Health Services Commissioned
Corps
Other: (Only for loans received prior to July 1, 1993)
Military Service (active duty):
Disabled Dependents
Branch of Service ________________________
Hardship
Internship for Professional Practice
Nursing Deferment Conditions:
National Oceanic and Atmospheric Administration
Officer in U.S. Public Health Services
At least half-time in a Nursing Program
Parental Leave
Advanced Professional Training
Peace Corp, VISTA, ACTION
Peace Corp/Volunteer
Temporary Total Disability
Military Service (active duty):
Volunteer in a Private Non-Profit Organization
Branch of Service ________________________
Working Mother
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
____ Part Time
Dates - From:____________
To:_____________
Signature of Certifying Official: ________________________________________
Title of Certifying Official: ____________________________________________
Date: _______________________
Ver042016
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