SC-NGDS-PS 12/20
AES Special Programs
Temporary Total Disability Deferment Request
AES Graduate and Professional Services
P.O. Box 2461
Harrisburg, PA 17105-2461
Fax: 717-720-3916
Please enter or correct the following information. If correction, check this box:
Account Number
Name
Address
City, State, Zip
Telephone -- Home
Telephone -- Mobile
Section 1
-
Deferment Request
- Must be completed by borrower or borrower's representative (a representative may complete and sign this section on my behalf if I
I meet the qualifications for a Disability Deferment and request that AES defer repayment of my privately insured loans.
If checked, to make interest payments on my loans during my deferment.
I certify that: (1) The information provided in Section 1 above is true and correct; (2) I will provide additional documentation, as required, to AES to support my
continued deferment status; (3) I will notify AES immediately when the condition that qualified me for the deferment ends; and (4) I have read, understand, and meet the
conditions of the deferment for which I have applied.
Borrower (Borrower's Representative) Signature/Date Name of Borrower's Representative
Send completed form to address listed above
am unable to do so because of my disability).
.
Defer (postpone) repayment of my account while I am TEMPORARILY TOTALLY DISABLED (Maximum eligibility is three years).
.
Defer (postpone) repayment of my account while I cannot secure employment by reason of the care required for my spouse, child or parent who
is disabled (Maximum eligibility is 12 months). Complete the following section:
Name of Disabled Spouse, Child or Parent
Relationship to Borrower
Borrower Authorization, Understandings and Certifications
I authorize any physician, hospital or other institution having records about the disability for which I am requesting deferment of payments to make information from these
records available to American Education Services (AES), or the National Guard.
I understand that: (1) My deferment will begin no more than six months before the date AES receives this request or the date the deferment condition began, whichever
is later; (2) My deferment will last no longer than six months after the date my physician certifies this request; (3) AES will not grant this deferment request unless all
applicable sections of this form are completed; and (4) Principal and interest payments will be deferred. I understand that any interest which accrues during my deferment
period will be capitalized to the extent such amounts are not paid by me prior to the conclusion of any approved deferment periods. This will increase the principal
balance of my privately insured loans.
Address of Borrower's Representative
Relationship to Borrower
Section 2 - Physician's Certification - Please print or type.
Instructions for Physician: You are being asked to complete and sign this form to certify that the disabled person is temporarily totally disabled. You may complete this
form only if you are a doctor of medicine or osteopathy, legally authorized to practice. Sign the certification only if the disabled person's condition meets the definitions
in the preceding cover letter. Please complete all requested information, you may attach additional pages if necessary.
- -
- -
The disabled person became unable to work and earn money, attend school or required continuous nursing or similar care on (MM-DD-YY)
and the
disabling condition or continuous care is expected to continue until (MM-DD-YY)
.
I certify that I am a doctor of medicine or osteopathy and legally authorized to practice and that in my best professional judgment, the disabled person named above is
unable to work and earn money because of a medically determined impairment.
Physicians Signature/Date
Address
Physicians Name
