FINANCIAL AID OFFICE
Financial Aid Office * 96-045 Ala Ike Street * Pearl City * 96782
Phone: 808 455-0606 * Fax: 808 453-6371 * Website: www.leeward.hawaii.edu/finaid, MyUH Services: https://myuh.hawaii.edu
2020-2021 Loan Discharge Form
The National Student Loan Data System (NSLDS) indicates that you have one or more student loans discharged due to your
total and permanent disability. Before you can receive additional federal student loans for the 2020-2021 academic year,
you must complete this form and return it to our office.
_____________________________________________ ______________________ _______________________
Last Name First Name UH ID/Username Phone Number
_______________________________________________________________________ ___________________________
Address City State Zip Code Email Address
Check only ONE box below:
I am NOT interested in applying for a student loan for the 2020-2021 academic year at Leeward CC.
Student Signature: ________________________________________________ Date: _________________________
Electronic signature or digital signature will NOT be accepted.
STOP: You do NOT have to complete the remainder of this form. Please return it to our office.
I am interested in applying for a student loan for the 2020-2021 academic year at Leeward CC.
By signing below, I acknowledge that any federal student loans I receive hereafter cannot be discharged in the future
on the basis of any present impairment or condition, unless the impairment or condition substantially deteriorates to
the extent that the definition of total and permanent disability is met.
Student Signature: ________________________________________________ Date: _________________________
Electronic signature or digital signature will NOT be accepted.
You must also complete/submit the following:
1. Obtain a signed physician’s certification on official letterhead that verifies your ability to engage in substantial
gainful activity. For Title IV aid purposes, the phrase “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
only need to submit the physician’s certification ONCE to our office, therefore if you have submitted one for a
prior year, you do not need to submit another one. You must attach your physician’s certification to this form.
Please note that our office may contact your physician if we have any questions or concerns.
2. 2020-2021 Federal Direct Student Loan Request Form (available online to download at:
https://www.leeward.hawaii.edu/finaid-docs-forms
or pick up in our office).
University of Hawai'i institutions do not discriminate on the bases of age, race, sex, color, national origin, or disability in its programs and
activities. For more information or inquiries regarding these policies, please contact the individual campus Title IX Coordinator. UH Title IX
Coordinators' names and contact information are available at: https://www.hawaii.edu/titleix/help/coordinator/
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