937.328.6034 | ﬁnancialaid@clarkstate.edu | 570 East Leel Lane, Springﬁeld, Ohio 45505
2020-2021 Certiﬁcation of Total and
Permanent Disability Discharge
The Financial Aid Oce received the Free Application for Federal Student Aid (FAFSA) you
submitted for the 2020-2021 academic year. It was indicated on the FAFSA that one or more of your
federal student loans have been discharged due to permanent and total disability. Please complete
and provide the information requested below. The information must be conﬁrmed before ﬁnancial
aid can be awarded.
SECTION A: Student Information
Name____________________________________________ Student ID Number___________________
_____________________________ ______________________________ ___________ _____________
Street City State Zip
Home Phone _________________________________ Work Phone _____________________________
Having requested and had conditionally discharged an obligation for repayment of previous Federal
Family Education Loan Program loans (FFELP) or Federal Direct Loans due to permanent and total
disability, I do arm that any new loans for which I may apply and receive, cannot be cancelled in
the future based on the previously claimed circumstances or impairment.
I have attached the following (required):
• A letter from my physician certifying that my disability does not prevent me from engaging in
substantial gainful activity such as working or attending school.
SECTION B: Student Certiﬁcation Statement
I certify that all of the information on this form and accompanying documents are true and complete
to the best of my knowledge. Furthermore, I arm that I have not knowingly or intentionally provided
any false or fraudulent documentation.
Student Signature ____________________________________________ Date_____________________