Fillable Conditional Discharge And Physician Statement

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Conditional Discharge And Physician Statement

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U.S.A. forms for Maysville Community and Technical College

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Conditional Discharge
*Your financial aid will not be processed without the physician’s certification to support your
request for new federal loans.
Eligibility Requirements to Receive Future Loans during Conditional Discharge
A borrower, whose prior loan was conditionally discharged due to total and permanent
disability, must complete this form.
If you do not wish to take out loans please check the box below, sign and
return.
☐ I do not wish to receive student loans, I am only interested in receiving the Pell grant.
If y
ou wish to receive loans, please review the statements below, and
provide the physician’s certification form on page 2.
1. Obtain a certification from a Physician stating that you have the ability to engage in
substantial gainful activity.
*This generally means that you have sufficiently physically recovered to be capable of
attending school, successfully completing a program of study, and securing employment
in order to repay the new loan you are seeking.
2. By signing below, you acknowledge that neither the previous conditionally discharged
loan(s) nor the new loan you receive can be discharged in the future on the basis of any
injury or illness present when you applied for a total and permanent disability discharge
or at the time the new loan is made, unless your condition substantially deteriorates so
that you are again totally and permanently disabled.
3. By signing below, you acknowledge that the conditionally discharged loan(s) will be
removed from conditional discharge status and that ED has removed the conditionally
discharged loan(s) from conditional discharge status.
______________________________ ___________________________
Student’s Signature Date
______________________________ ___________________________
Student Name Student ID
Loan Discharge Physician Certification
Bor
rower Name:_____________________________ Date: ____________________
Borrower Address:_____________________________________________________________________
Borrower Phone:________________________ Borrower SSN:__________________________
I authorize the release of medical information on this form pertinent to my schools, lenders, guarantor,
subsequent holder, the U.S. Department of Education, and their agents.
Borrower Signature: _____________________________ Date:_______________
Physician Certification
The above referenced borrower was previously classified as totally and permanently disabled and
received a discharge for their student loans as a result of that classification. The borrower is requesting
more student loans from one of the federal educational loan programs. Please respond to the questions
below as required by the U.S. Department of Education.
Is the borrower totally and permanently disabled? Y☐ N☐
Is the borrower able to attend school? Y☐ N☐
Is the borrower able to engage in gainful employment? Y☐ N☐
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
Phy
sician Address and Phone:____________________________________________________________
Physician Name (Print): ___________________________________
Phy
sician Signature/Date: _________________________________
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Conditional Discharge And Physician Statement

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Completed 4 December 2019

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