PHYSICIAN’S CERTIFICATION
OF
BORROWER’S TOTAL AND PERMANENT DISABILITY
Department of Education Student Loan Programs
GENERAL INSTRUCTIONS:
This form is used for obtaining a physician’s certification of a borrower’s permanent and total disability for the purpose of cancellation of the
borrower’s obligation to repay his or her student loan(s) obtained under one or more of the following student loan programs:
Guaranteed Student Loan Program (GSLP)
Health Education Assistance Loan (HEAL)
National Defense of Direct Student Loans (NDSL)
United States Loan Program for Cuban Students (USLPCS)
This form is recommended but not required for NDSL Loans.
NOTE: Borrowers who owe GSLP loans and who are only partially or temporarily disabled may be eligible for a loan deferment if the borrower is
in enrolled in a an approved rehabilitation program. To determine which rehabilitation programs can be approved, the borrower should check with
the Regional Office, Department of Education.
DEFINITION OF TOTAL AND PERMANENT DISABILITY
TO BE TOTALLY AND PERMANENTLY DISABLED THE BORROWER MUST BE UNABLE TO ENGAGE IN ANY SUBSTANTIALLY
GAINFUL ACTIVITY BECAUSE OF A MEDICALLY DETERMINED IMPAIRMENT THAT IS EXPECTED TO CONTINUE FOR A LONG AND
INDEFINITE PERIOD OF TIME OR RESULT IN DEATH.
This definition calls for a judgment decision as to the borrower’s ability to earn income despite his or her disability. The physician is to assess the
impact of the borrower’s disability on his or her ability to earn income in comparison to what the borrower would normally be able to earn if he or
she were not disabled. If the disability appears to have a significant adverse effect on the borrower’s earning potential, not only in the type of work
performed before the impairment but for any substantial gainful emp loyment, and the disability is expected to last for a long and indefinite period
of tim, then the borrower shall be considered permanently disabled under this definition.
It should be noted that the standard for determining disability for cancellation of the borrower’s loan obligation may be different from standards used
under other public and private programs in connection with occupational disability or eligibility for social service benefits.
INSTRUCTIONS FOR SECTION 1 - BORROWER
INSTRUCTIONS FOR SECTION II - PHYSICIAN
1. A representative of the borrower may complete this section 1. You are being asked to complete and sign this form to
and sign the form on the borrower’s behalf if the borrower
certify that the borrower is totally and permanently
is unable to do this because of his or her disability. disabled.
2. Have Section II of the form completed and signed by a
2. You may complete this form for the borrower only if you
doctor of medicine or doctor of osteopathy. are a doctor of medicine or doctor of osteopathy legally
authorized to practice in your state.
3. Return two completed copies of this form to each lender
3. Sign the certification only if the borrower’s condition
which has made a loan to you under any of the student meets the above definition of total and permanent disability.
4. Please make your report complete as to the nature, duration,
and severity of the borrower’s present and future
impairment. You may attach additional pages if necessary.
Privacy Act Notice — The Privacy Act of 1974 (5 U.S.C. 552a) requires that an agency provide the following notice to each individual whom it
asks to supply information.
1. The authority for collecting the information requested on this form is found in 20 U.S.C. 1087, 42 U.S.C. 2094k, and
22 U.S.C. 2601.
2. The principal purposes of this information are to verify the identity of the borrower; determine eligibility for loan cancellation; and in the
event it is necessary to locate the borrower’s representative or certifying physician. The SSN is used as a loan account number (identifier)
in order to accurately record necessary information.
3. The routine uses of this information include its disclosure to Federal, State or local agencies, to guarantee agencies, to educational and
financial institutions and to agency contractors for the purpose of; verifying the identity of the borrower and the borrower’s physician;
determi ning the borrower’s eligibility for loan cancellation; investigating possible fraud and verifying compliance with program
regulations. Failure to provide the requested information may cause the Department of Education to deny the borrower’s request for loan
cancellation.
4. This information is necessary to process requests for loan cancellation
