Central Alabama Community College
Student’s Name: __________________________ Student Number: _________________________
Address: __________________________________ Phone Number: ___________ Date of Birth: _________
Please note: This document, like all student financial aid records, is protected for privacy by the Family Education Rights
& Privacy Act (FERPA), (1974), the Financial Modernization Act of 1999, also known as the Gramm-Leach-Bliley Act,
and by the Fair and Accurate Credit Transactions Act of 2003.
By signing this form, I, the student, acknowledge that I can’t get a Total and Permanent Disability (TPD)
discharge of the new loan (if eligible) or TEACH Grant (if eligible) based on a disabling condition that already
exists when I receive the new loan or TEACH Grant, unless that condition substantially deteriorates in the future.
I understand that if I received a TPD discharge based on SSA documentation or a physician’s certification and
my three-year post discharge period hasn’t ended, I must also resume repayment on your previously discharged
loans or acknowledge that I am once again responsible for meeting the terms and conditions of your TEACH
Grant service obligation.
The student’s signature authorizes the release of the information requested within this document.
_________________________________________ _________________________________________
t Signature Date
To be completed by the student’s Physician
The student named above will be attending Central Alabama Community College (CACC) and would like to receive
federal student aid. Because the student has had previous federal student aid discharged on the basis of total and
permanent disability, federal regulations require the student to obtain certification from a doctor of medicine or a doctor
of osteopathy that he or she is no longer totally and permanently disabled before regaining eligibility for certain types
of federal student aid.
By signing this form, you (the physician) are certifying that the above named student is your patient and is capable
of substantial gainful activity. As defined in federal regulations,substantial gainful activity” means a level of
work performed for pay that involves doing significant physical or mental activities or a combination of both. You
are also certifying that you are a doctor of medicine or osteopathy who is legally authorized to practice in a state of
the United States or its territories.
_______________________________________________________ ____________________________
Physician’s Name (print) MD or DO
______________________________________________________ _____________________________
Physician’s Signature Date
City State Zip
Phone Email
*State includes the 50 United States, the District of Columbia, American Samoa, the Commonwealth of Puerto Rico, Guam, the Virgin Islands, the Commonwealth of
the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau
Please return the completed form to:
Central Alabama Community College Financial Aid Office
Alexander City Campus: 1675 Cherokee Road, Alexander City, AL 35010 OR Childersburg Campus: 34091 US Highway 280, Childersburg, AL 35044