Lorain County Community College Financial Services 1005 N. Abbe Rd, Elyria, OH 44035 Fax: 440-366-4634 Page 1 of 1
Borrower Acknowledgement Statement
2020-21 Financial Aid Year
Section 1. Student Information
Last Name First Name Middle Initial
LCCC Student ID #
We have completed the initial review of your 2019-2020 Free Application for Federal Student Aid (FAFSA). Through a database
match, the U.S. Department of Education has identified that you have had one or more loans discharged due to total and permanent
disability. Please complete this form, attach the appropriate documentation, and return it to the Financial Aid Office as soon as
Please be advised that further processing of your aid has been delayed until
this form and all documents are returned and verified.
Please check the boxes that apply to you and attach the requested documentation:
I have had one or more loans discharged due to total and permanent disability.
ATTACHED is a signed certification from my physician that I have the ability to engage in substantial gainful activity.
My loan(s) were not discharged due to total and permanent disability.
Section 2. Certification.
I acknowledge that I am aware that the new Federal Student Loans or TEACH grant service obligations that I obtain cannot later be
discharged for any present impairment unless it deteriorates so that I am again totally and permanently disabled. I certify that the
information given on this form is true and complete.
I certify that all of the information reported is complete and accurate. Warning: If you purposely give false or misleading information on
this worksheet, you may be fined, sentenced to jail, or both.
Student Signature: Date
Electronic signatures will not be accepted. Please print this form to sign before submitting.
Section 3. Submission
You may submit your information by: a) mail to the address below; b) fax to 440-366-4634 or; c) deliver to Financial Services, First Floor, Bass Library. Do not email
any documents with personally identifiable information.