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DISADVANTAGED, NURSING, PRIMARY CARE, HEALTH PROFESSIONS AND R.W. (Oregon Health Sciences University)

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DISADVANTAGED, NURSING, PRIMARY CARE,
HEALTH PROFESSIONS AND R.W. JOHNSON LOANS
REQUEST FOR DEFERMENT OF REPAYMENT
INSTRUCTION ON BACK OF FORM
PART I - GENERAL INFORMATION (To be completed by borrower)
Borrower is responsible to advise OHSU of current address!
E-MAIL ADDRESS:
NAME OF BORROWER
SOCIAL SECURITY NUMBER
STREET ADDRESS
NAME OF LENDING INSTITUTION
(College/University from which loan originated)
OREGON HEALTH & SCIENCE UNIVERSITY
_________________________________________________
SEND COMPLETED FORM TO:
Educational Computer Systems Inc.
181 Montour Run Road
Coraopolis, PA 15108-9408
1-888-549-3274
CITY, STATE, ZIP
HOME PHONE NUMBER
WORK PHONE NUMBER
PART II - REQUEST FOR DEFERMENT OF REPAYMENT (To be completed by borrower)
A. Ceases to pursue the course of study at:
1. A school of medicine, osteopathy, dentistry, pharmacy, podiatric medicine, optometry, or veterinary medicine, but (1) re-enters the
same or another such school within the applicable grace period; or (2) engages in a full-time educational activity as defined by
regulations of the Secretary of Health and Human Services, with the intent to return to the school as a full-time student.
2. A school of nursing leading to a diploma or associate degree in nursing, a baccalaureate degree in nursing or an equivalent degree, or
to a graduate degree in nursing, but re-enters the same or another such school within the applicable grace period.
This is to certify that I was a full-time health professions or full or half-time nursing student at
from to pursuing a
course of study leading to a
degree.
B. Performs active duty as a member of a uniformed service or as a volunteer under the Peace Corps Act.
This is to certify that I was in the (enter Peace Corps or name of uniformed service)
from to _______________
C. (1) For Health Professions, Primary Care, Disadvantaged Students, and R.W. Johnson Student Loan
Borrowers:
Pursues advanced professional training, including internships and residencies or participates in a fellowship training program or full-
time educational activity, as defined by regulations of the Secretary of Health and Human Services.
(2) For Nursing Student Loan Borrowers:
Pursues at least half-time or better course of study at a collegiate school of nursing leading to a baccalaureate degree in nursing or an
equivalent degree, or to a graduate degree in nursing, or is otherwise pursuing advanced professional training in nursing.
This is to certify that I was pursuing advanced professional training at
from to ________________
D. Pursues training as a nurse anesthetist at: ________________________________________________
from
to .
DATE:
SIGNATURE OF BORROWER:
-OVER-
Print Form
INSTRUCTIONS
You as a borrower of a HPSL, LDS, PCL or NSL, are responsible for the completion and return of this form to the institution form
which you received loans. You should request immediate completion by the official authorizing your status in deferment. If you
fail to submit this form to your school by the payment due date, your school is required to consider your loan past due, and must
take actions to collect as required by HPSL, LDS, PCL and NSL regulations, including the use of collection agents, credit bureau,
and litigation.
To request deferment of repayment on your HPSL, LDS, PCL or NSL, this form must be filed with the school which made the
loan at each of the following times:
(1) when your first repayment installment is due,
(2) annually thereafter as long as you are eligible for such deferment, and
(3) when you cease to be in eligible deferment status.
A copy of the form, properly executed, as submitted to the school, should be retained for your own record.
PART III - CERTIFICATION OF DEFERMENT STATUS (To be completed by Official Authorizing Borrower(s) status)
A. To be completed by official of institution where borrower enrolled or is pursuing advance professional training.
I certify that the information stated in (Check appropriate space) Part II:
A1 A2 C1 C2 (or) D above is true and correct.
I certify that his/her advance professional training is from
to ________________ .
NAME AND ADDRESS OF SCHOOL OR HOSPITAL:
PHONE NUMBER: ( )
NAME AND TITLE OF AUTHORIZED OFFICIAL:
SIGNATURE OF AUTHORIZED OFFICIAL:
DATE:
B. To be completed by the Commanding Officer or Peace Corps Official.
I certify that the information stated in Part II - B, above is true and correct.
Borrower(s) Uniformed Service* Serial Number:__________________________________________________
* The uniformed services of the United States are the Army, Navy, Marine Corps, Air Force, Coast Guard, National Oceanic and
Atmospheric Administrations Corps, and the U.S. Public Health Service Commissioned Corps.
NAME AND ADDRESS OF UNIFORMED SERVICE OR PEACE
CORPS
NAME & TITLE/RANK OF COMMANDING OFFICER OR PEACE
CORPS HEADQUARTERS:
SIGNATURE OF COMMANDING OFFICER OR PEACE CORPS
OFFICIAL:
DATE:
PART IV - INSTITUTIONAL ACTION (To be completed by school from which loan was made)
APPROVED FROM TO
SIGNATURE OF APPROVING OFFICIAL:
DISAPPROVED REASON FOR DISAPPROVAL:
DATE:
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DISADVANTAGED, NURSING, PRIMARY CARE, HEALTH PROFESSIONS AND R.W. (Oregon Health Sciences University)

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Completed 23 July 2020

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