2019-2020 Federal Loan Discharged Due to Disability
Instructions:
Our office has received information from the National Student Loan Data System (NSLDS) indicating that you have had one or more
prior student loans discharged due to total and permanent disability. In order for our office to continue processing your financial aid,
we need you to clarify whether or not you want additional loan consideration.
Please allow 7-10 business days for processing, or longer
during peak processing periods.
Student Information
To Be Completed by Student:
Student Loan Information (Initial Below)
__________ I do want to be considered for additional student loan funds.
Complete Borrower Certification Statement.
Your physician will need to complete the Physician’s Certification Statement below.
__________ I do not want to be considered for additional student loan funds.
You will be considered for other types of assistance, but will not be considered for student loans.
Cer
tification and Signature
I understand that neither any new loan(s) nor conditionally discharged loan(s) can be discharged on the basis of any present impairment
unless it deteriorates so that I am again totally and permanently disabled.
Student’s Signature (electronic signature NOT accepted)
Date
Physician’s Certification Statement
I certify that my patient (the student identified on this form) has a disability condition that has improved and that the student, has the
ability to engage in substantial gainful activity. Note: the phrase “substantial gainful activity” generally describes a situation in which a
student is sufficiently physically recovered to be capable of attending school, successfully completing a program of study, and securing
employment.
Physician Signature
Physician Name
(please print)
Date
Specialty
Office address (city,state,zip)
Phone Number
34CFR 674.61 (B) Perkins
34CFR 685.21 DL
Non-D
iscrimination Statement
The Maricopa County Community College District (MCCCD) is an EEO / AA institution and an equal opportunity employer of protected veterans and individuals
with disabilities. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity,
age, or national origin. A lack of English language skills will not be a barrier to admission and participation in the career and technical education programs of the
District.
The Maricopa County Community College District does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs or
activities. For Title IX / 504 concerns, call the following number to reach the appointed coordinator: (480) 731-8499. For additional information, as well as a
listing of all coordinators within the Maricopa College system, visit http://www.maricopa.edu/non-discrimination.
Discharge
WARNING
If you purposely give misleading or false information on this form, you may be fined, be sentenced to jail, or both.
Last Name (Print) First Name (Print) MI Student ID Number
Maricopa Email Address Phone Number with Area Code
@maricopa.edu
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