Fillable 1833 W Southern Ave, Bldg 39, Mesa, AZ (Mesa Community College)

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1833 W Southern Ave, Bldg 39, Mesa, AZ (Mesa Community College)

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1833 W Southern Ave, Bldg 39, Mesa, AZ 85202 / FAX 480-844-3272 / Submit form via FAX or In-person
PARENT BORROWER INFORMATION- The definition of a parent borrower is the natural or adoptive parent of the student listed above, or
the spouse of the natural or adoptive parent of the student listed above.
IMPORTANT: If you wish to reduce or cancel your PLUS Loan, you must notify our office within 14 days after receipt of the funds.
I author
ize Direct Loan (or its agent) to obtain a credit bureau report for the purpose of making a preliminary determination of whether I meet the
credit eligibility requirements for a PLUS loan. I also authorize Direct Loans to disclose the preliminary credit decision to: Mesa Community
College School Code: 001077 By signing below, I understand that any conditional approval I receive based upon the review of my credit will
be subject to verification, or additional financial information that Direct Loans may require (including, in some cases, an updated credit bureau
report), verification of my eligibility to borrow under the Federal PLUS Loan Program, and receipt of a signed completed PLUS Loan Application
and Promissory Note. The conditional approval does not ensure guarantee of the PLUS Loan. Student loan history, including prior defaults, may
impact final approval.
X
Signature of Parent Borrower
Date
We mu
st have the proper parental signatures on this form. We are here to assist students and need to follow the guidelines that are
placed upon us. Anyone who attempts to provide false or misleading information may be fined up to $20,000 or turned over to the
Inspector General’s Office.
FOR SCHOOL USE ONLY: Approved ______ Denied ______ DATE: ___________ BY: ______ SAP: Met ______ Not Met ______
STUDENT INFORMATION
Student Name
Student ID No.
Student Date of Birth
Student SSN
Parent Borrower Name
Parent SSN
Date of Birth
Home Phone Number
Email Address
Driver’s License No.
State Issued
Employer
Employer Phone No.
Circle One: U.S. Citizen / *Eligible Non-Citizen
*Alien Registration No (If applicable) :
Loan Amount Requesting: $
Term and Year Requested for:
Fal
l____________ Spring ____________ Summer ______________
Federal Direct PLUS Loan Request
Parent Loan for Undergraduate Students
1833 W
Southern Ave, Bldg 39, Mesa, AZ 85202 / FAX 480-844-3272 / Submit form via FAX or In-person
Consent to Obtain Credit Report
I, ____________________________________________________, give consent to Mesa Community
College, the U.S. Department of Education, and/or its agents, to access my credit report for the sole
determination of whether I will be approved for a PLUS Education Loan. I understand that I will be notified
of the results of the credit check with respect to my loan application.
Last Name
First Name
M.I.
Address
Apt. No.
Phone No.
City
State
Zip Code
Borrower’s Signature
Date
Privacy Act Disclosure Notice
The P
rivacy Act of 1974 (5 U.S.C.552a) requires that the following notice be provided to you. The authority for collection the information requested
on this form is §451 et seq. of the Higher Education Act of 1965, as amended. Your disclosure of this information is voluntary. However, if you
do not provide this information, you cannot be considered for a Direct PLUS Loan. The information on this form will be used to determine your
eligibility for a Direct PLUS Loan. The information in your file may be disclosed to third parties as authorized under routine uses in the Privacy
Act notices called “Title IV Program Files” (originally published on April 12, 1994, Federal Register, Vol. 59 p. 17351) and “National Student Loan
Data System” (originally published on December 20, 1994, Federal Register, Vol. 59 p. 65532). Thus, this information may be disclosed to
federal and state agencies, private parties such as relatives, present and former employers and creditors, and contractors of the Department of
Education for purposed of administration of the student financial assistance program, for enforcement purposes, for litigation where such
disclosure is compatible with the purposes for which the records were collected, for use by federal, state, local, or foreign agencies in connection
with employment matters or the issuance of a license, grant, or other benefit, for use in any employee grievance or discipline proceeding in which
the federal Government is a party, for use in connection with audits or other investigation, for research purposes, for purposes of determining
whether particular records are required to be disclosed under the Freedom of Information Act, and to a Member of Congress in response to an
inquiry from the congressional office made at your written request.
Because we request your social security number (SSN), we must inform you that we collect your SSN on a voluntary basis, but section 484(a)(4)
of the HEA (20 U.S.C. 1091(a)(4)) provides that, in order to receive any grant, loan, or work assistance under Title IV of the HEA, a student must
provide his or her SSN. Your SSN is used to verify your identity, and as an account number (identifier) throughout the life of your loan(s) so that
data may be recorded accurately.
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1833 W Southern Ave, Bldg 39, Mesa, AZ (Mesa Community College)

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Completed 25 July 2020

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