Borrower Signature
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 forbearance request.
READ BEFORE COMPLETING FORM. ALL ITEMS RELEVANT TO YOUR REQUEST MUST BE COMPLETED.
**INCOMPLETE ITEMS MAY BE CAUSE FOR DENIAL**
Ed-Invest
Email Address:
Telephone Number:
Alternate Telephone Number:
City:
Zip Code:
Address:
Borrower Name:
Borrower Account Number:
SECTION 1: BORROWER INFORMATION
Zip Code:
Employer Name:
EmployerTelephone Number:
Address:
Telephone Number:
Institution/Organization Name:
DOE Code:
SECTION 2: MEDICAL INTERNSHIP/RESIDENCY FELLOWSHIP AUTHORIZED OFFICIAL'S CERTIFICATION
I meet the qualifications as stated in the cover letter for a Medical Internship/Residency Deferment 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 change, I must notify my lender/servicer immediately.
SECTION 3: DEFERMENT AGREEMENT
State:
State:
I certify that the borrower is eligible for the deferment and meets all of the requirements on the cover sheet.
Program Begin Date:
Program End Date:
City:
My signature indicates that I am an Authorized Official and the certification above is true to the best of my knowledge
Return completed form to: American Education Services * P.O. Box 2461 * Harrisburg, PA 17105-2461
Date
MEDICAL INTERNISHIP/RESIDENCY FELLOWSHIP DEFERMENT REQUEST
Date
