1900 West 50
th
Street Marion, IN 46953-9393 indwes.edu
Financial Aid Office, IWU National & Global
800.621.8667 option 4
765.677.2516 765.677.2030 Fax IWUfinaid@indwes.edu
The National Student Loan Data System (NSLDS) indicates that you have one or more student loans discharged
because of a total and permanent disability. Before you can receive additional federal student loans, this form must
be completed and returned to the financial aid office.
Borrower Information
Name: ______________________________________ ____ __________________________________________
First M.I. Last
Date of birth: _______/_______/_______ Student ID: ____________________ OR SSN: _____________________
Title IV Student Aid Consideratons
I do not wish to receive William D. Ford Federal Direct Loans; I wish to apply for Pell Grant only.
OR
I wish to be considered for federal Title IV student loans. I have included my completed Physician’s
Certification (or one is already on file with the financial aid office). Additionally, I certify the following:
I am able to engage in substantial gainful activity as indicated by my completed Physician’s
Certification.
I am aware that new Title IV student loans cannot later be discharged for any present impairment
unless it deteriorates so that I am again permanently disabled.
I am aware that collection activity will resume on any Title IV loans in a post-discharge monitoring
period.
If I am attempting to obtain new loans within the three-year post-discharge monitoring period,
I acknowledge that the suspension of collection activity on the conditionally discharged loan
will be lifted.
In addition, the suspension of collection activity on the conditionally discharged loan must be
lifted before I (the borrower) can receive the new loan. This means that the loan is no longer
conditionally discharged and I am responsible for repaying it.
Unless my condition substantially deteriorates, the old loan(s) cannot be discharged in the
future for any impairment present when I began the conditional discharge or when I tried to
get the new loan.
Signature and Affirmation
Student’s signature: _____________________________________________________ Date: _________________
Warning: If you receive student aid based on incorrect information, you may have to return it and/or pay fines and fees. If you purposely
give false or misleading information on this form, you may be fined $20,000, and receive a prison sentence, or both.
Affirmation: By signing above, I certify that all information I have submitted is accurate and verified with supporting documentation.
Definitions
Substantial Gainful Activity A level of work performed for pay that involves doing significant physical or mental activities or
a combination of both.
Post-discharge monitoring period The three-year period beginning on the date your discharge is approved in which your
obligation to repay your discharged federal student loans will be reinstated if: 1) You have annual employment earnings
that exceed the Poverty Guideline amount for a family of two in your state, regardless of your actual family size; 2) You
receive a new William D. Ford Federal Direct Loan (Direct Loan) Program loan, Federal Perkins Loan (Perkins Loan)
Program loan, or TEACH Grant; 3) A disbursement of a Direct Loan, Perkins Loan, or TEACH Grant that you received
before the discharge date is made, and you do not ensure the return of the full amount of the disbursement within 120 days
of the disbursement date; or 4) You receive a notice from the SSA stating that you are no longer totally and permanently
disabled, or that your disability review will no longer be the 5-year or 7-year review period indicated in your most recent
SSA notice of award for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits.
ACKNOWLEDGEMENT OF
NATIONAL & GLOBAL
FINANCIAL AID OFFICE
