CITIZENS BANK, N.A.
ADDRESS
EMAIL ADDRESS
ACCOUNT NUMBER
CITY ZIP CODE
TELEPHONE NUMBER
I consent to the lender and any other owner, holder, servicer, guarantor or insurer of my account to contact me about
my account via autodialer or similar device and/or using a prerecorded or artificial voice or message for any lawful
purpose utilizing any cellular telephone number(s) I provide, even if I am charged for the call under my phone plan.
Providing my mobile or alternative telephone number(s) and electronic mail address(es) to the lender is voluntary
and I am under no obligation to do so. If I do not elect to provide a mobile or alternative telephone number, or
electronic mail address, it will not affect the consideration or disposition of my deferment request.
American Education Services* P.O. Box 2461
REQUEST FOR DEFERMENT
PLEASE COMPLETE ALL FIELDS BELOW. YOUR REQUEST MAY BE DENIED IF THE FORM IS NOT
COMPLETED CORRECTLY.
BORROWER/COSIGNER NAME
ALTERNATIVE TELEPHONE NUMBER
STATE
PEACE CORPS (I will enclose proof of my service with certification)
PARENTAL LEAVE (I will enclose either proof from my doctor confirming pregnancy, copy of newborn
birth certificate, or copy of adoption documentation).
ARMED FORCES/MILITARY (may be requested by borrower or cosigner) I will enclose a copy of my
current Active Duty orders. I understand that my request may be denied if my orders are not enclosed.
I would NOT like to invoke the Servicemembers Civil Relief Act (SCRA)
I meet the qualifications as stated in the cover letter for the deferment type checked above and request my
lender/servicer to defer repayment of my educational loan(s). If my loan program allows, accrued and unpaid
interest may be capitalized, added to the principal balance, in accordance with the terms of my original
promissory note. I understand that, should my situation under which I applied for the deferment changes, I
must notify my lender/servicer immediately.
RETURN COMPLETED FORM TO:
BORROWER SIGNATURE
Date
COSIGNER SIGNATURE
Date
FAX: 717-720-3916
Harrisburg, PA 17105-2461
.
