FEDERAL PERKINS LOAN PROGRAM
REQUEST FOR DEFERMENT OF REPAYMENT
PART I - GENERAL INFORMATION (To be completed by borrower)
Borrower is responsible to advise OHSU of current address! DATE EXITED SCHOOL
NAME OF BORROWER
SOCIAL SECURITY
NUMBER
STREET ADDRESS
PHONE NUMBER
EMAIL:
CITY, STATE, ZIP
YOUR SIGNATURE:
THIS IS TO CERTIFY THAT I AM: (check one)
( ) At least a half-time student at an institution of higher education
For NDSL loans made between October 1, 1980 and July 1, 1993 ONLY
MAXIMUM THREE YEAR DEFERMENTS FOR THE FOLLOWING:
( ) A member of the U.S. Army, Navy, Air Force, Marines, or Coast Guard
( ) A member of the National Guard or the Reserves serving a period of full-time active duty in the Armed Forces
( ) An officer in the Commissioned Corps of the U.S. Public Health Service or a Peace Corps volunteer
( ) A volunteer under Title I, Part A of the Domestic volunteer Service Act of 1973 (ACTION programs)
( ) A full-time volunteer in service for a tax-exempt organization ED has determined is comparable to Peace Corps or ACTION
( ) Temporarily totally disabled or unable to work because he/she must care for a spouse who is so disabled. A physician(s statement is
required to prove disability.
( ) Serving in an eligible internship program (maximum two year deferment)
For FEDERAL PERKINS loans made before July 1, 1993 ONLY
MAXIMUM THREE YEAR DEFERMENTS FOR THE FOLLOWING:
( ) A member of the U.S. Army, Navy, Air Force, Marines, or Coast Guard
( ) A member of the National Guard or the Reserves serving a period of full-time active duty in the Armed Forces
( ) An officer in the Commissioned Corps of the U.S. Public Health Service
( ) A Peace Corps volunteer, or a full-time active duty as a member of the National Oceanic and Atmospheric Administration Corps.
( ) A volunteer under Title I, Part A of the Domestic volunteer Service Act of 1973 (ACTION programs)
( ) A full-time volunteer in service for a tax-exempt organization ED has determined is comparable to Peace Corps or ACTION
( ) Temporarily totally disabled or unable to work because he/she must care for a spouse or other dependent who is so disabled
( ) Serving in an Aeligible internship/residency@ program (maximum two year deferment)
( ) Mother of a preschool-age child, provided the mother is going to work (or going back to work) at a salary that is no more than $1.00 in
excess of the minimum hourly wage (maximum one year deferment)
( ) Parental leave (pregnant, or if he or she is taking care of a newborn or newly adopted child) (maximum six month deferment)
( ) Hardship deferment as determined by the school (if the borrower is facing a prolonged period of illness or unemployment). However,
interest will continue to accrue during the deferment
For FEDERAL PERKINS and NDSLS loans made ON OR AFTER July 1, 1993 ONLY
( ) Enrolled and in attendance as a regular student in a course of study that is part of an approved graduate fellowship program approved ED
(the borrower must provide certification that he/she has been accepted for or is engaged in full-time study in the school=s graduate
fellowship program)
( ) Engaged in graduate or post-graduate fellowship-supported study (such as a Fulbright grant) outside the United States
( ) Serving in a residency program in DENTISTRY (deferments may no longer be granted to a borrower while serving in a medical
internship or residency program, except for a program in dentistry)
( ) Enrolled in a course of study that is part of an approved rehabilitation training program for disabled individuals approved by ED
( ) Seeking and unable to find full-time employment (maximum three year deferment)
( ) Suffering an economic hardship (maximum three year deferment)
PART II - CERTIFICATION TO BE COMPLETED BY SCHOOL OR APPROPRIATE OFFICIAL ON BACK
Print Form
PART II - CERTIFICATION (to be completed by school or appropriate official)
I CERTIFY THAT THE INFORMATION STATED IN PART I IS TRUE AND CORRECT; THE PERSON NAMED IN PART I IS (WAS):
ENROLLED AS AT LEAST A HALF-TIME STUDENT A VOLUNTEER UNDER THE DVS ACT OF 1973
ON FULL-TIME ACTIVE DUTY IN ARMED FORCES SERVING AN ELIGIBLE INTERNSHIP OR RESIDENCY
IN PEACE CORPS VOLUNTEER SERVICE AN OFFICER IN THE U.S. PUBLIC HEALTH SERVICE
ON ACTIVE DUTY IN NOACC A VOLUNTEER IN A NON-PROFIT, TAX-EXEMPT ORGANIZATION
SPECIFIC DATES: FROM: TO:
SIGNATURES (REGISTRAR, COMMANDING OFFICER, PEACE CORPS OR VOLUNTEER OFFICER)
DATE
NAME OF INSTITUTION OR ORGANIZATION
OFFICIAL SEAL OR STAMP OR
SCHOOL/ORGANIZATION *
ADDRESS (CITY, STATE AND ZIP CODE)
PHONE AND AREA CODE
* If an official seal or stamp is not available, the appropriate official must verify your status on official letterhead stationery.
Student deferment forms must be certified only after classes begin.
PART III - OHSU USE ONLY
FORM PROCESSED BY:
NEXT PAYMENT DATE
PAST DUE AMOUNTS
PRINCIPAL
INTEREST
DATE:
PAYMENTS DEFERRED
LATE CHG
TOTAL
SIGNATURE OF APPROVING OFFICIAL
TITLE DATE
INSTRUCTIONS:
1. PLEASE PRINT IN INK, OR TYPE
2. Complete Part I
3. Sign and date form
4. Have forms certified in Part II (FORMS WILL BE RETURNED IF ANY INFORMATION IS MISSING)
5. Return forms and any accompanying verification documents to:
SEND COMPLETED FORM TO:
Educational Computer Systems Inc.
181 Montour Run Road
Coraopolis, PA 15108-9408
1-888-549-3274
$0.00
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