Certification of Loan
Discharge Status Form
Students who have received federal student aid (FSA) funds for which they are obligated to repay but have had their
repayment obligations canceled (discharged) due to disability must complete this form to request FSA be awarded. To
request federal grants only, students must complete Parts A, B, and D. To request federal loans, students must also have
his/her physician complete Part C. To be eligible for FSA, students must meet general FSA eligibility requirements.
Part A: Student Information
Name:
SID#:
SSN:
Home Phone No.:
Street Address:
City:
Zip Code:
E-mail
Address:
Part B: Federal Student Aid Request
Please check the appropriate box which describes the types of FSA you would like to apply for at Edison State Community
College
Federal grants only. (Skip Part C and complete Part D)
Federal grants and federal loans.* (Complete both Part C and Part D)
* If less than three (3) years have passed since the date of your loan discharge, you may need to resume payment on your discharged
loan(s) or acknowledge that you are once again subject to the terms of the TEACH Grant agreement to serve.
Part C: Physician Certification for Federal Loan Eligibility
Instructions for Physician: You are asked to certify that the student named in Part A above is able to engage in substantial
gainful activity. The U.S. Department of Education defines “substantial gainful activity” as, “a situation in which a borrower
is sufficiently fully recovered to be capable of attending school, successfully completing a program of study, and securing
employment in order to repay the loan the borrower is seeking.” The student named in Part A, for whom you are
completing this certification, has previously had one or more FSA funds discharged due to disability. At the time of that
discharge, a physician certified that the borrower was unable to engage in any substantial gainful activity due to a medically
determinable impairment which was expected to continue for a long and indefinite period of time.
In my best professional judgment, I certify the student named in Part A is able to engage in substantial gainful
activity as defined by the U.S. Department of Education.
Additional Comments:
Physician Name:
Street Address:
City:
State:
Zip Code:
Signature of Physician (M.D. or D.O.):
Part D: Student Certification
I acknowledge that I have previously had one or more FSA funds discharged due to disability. I understand if I requested
to be considered for federal loans and new loans are awarded to me, I must repay these new loans and they may not be
canceled on the basis of any impairment present at the time the new loans are made, unless my impairment substantially
deteriorates as determined by my physician. I understand that a copy of the completed form will be sent to the physician
named above by the Office of Student Financial Aid.
Student’s Signature:
Date:
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