Fillable Form 2.: APPLICATION FOR HARDSHIP/UNEMPLOYMENT DEFERMENT (Brandeis University)

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Form 2.: APPLICATION FOR HARDSHIP/UNEMPLOYMENT DEFERMENT (Brandeis University)

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APPLICATION FOR HARDSHIP/UNEMPLOYMENT DEFERMENT
(You must fill out both sides of this form)
Name: ___________________________________ Account Number(s) ________________________
Address: ___________________________________ ________________________
___________________________________ ________________________
Telephone: ____________________ (home) ________________________
____________________ (work) Social Security No. ________________________
I request deferment of my student loan(s) payments, beginning _______ and ending ______. I meet the qualification(s) I have checked below, and I have
attached the required documentation. I understand that the maximum benefit is three years, which will be granted to me in periods of not more than six
months at a time. Read this entire form before you fill it out. If you do not qualify for any of these benefits, please send a request for forbearance.
1.
Prolonged illness, starting ______ and ending _______. Attach explanation of how your health affects your ability to pay this loan(s). Provide
physician statement of diagnosis, and submit with this application. Complete the Income & Expense Summary on reverse side. I understand that
interest accrues during this type of deferment.
2.
Unemployed since _______. Provide documentation such as proof that you are collecting unemployment benefits and, if you are still unemployed,
that you are actively seeking employment (attach a list of firms where you have applied for employment, including the firms' name and address, and
the name and telephone number of a person to contact for verification); or
working part time and unable to find full-time employment (full time = 30 hours per week for three consecutive months). I have not worked full
time since __________. To receive deferment of payments under this provision, provide one of the following information:
I registered with the following public or private employment agency (does not include school placement offices or temporary employment
agencies):
Name of agency:___________________________________ Address: _______________________________________
Contact: ___________________________________ _______________________________________
Telephone: ___________________________________ _______________________________________
I have not registered with an employment agency (attach explanation).
In the last six months, I have attempted to secure employment. Attach a list of firms where you have applied for employment, including the
firms' name and address, and the name and telephone number of a person to contact for verification.
3.
I have been granted an Economic Hardship Deferment on my other federal loan(s) for the period starting ________ and ending _______, and I
request this same deferment, for the same period of time, on my Federal Perkins Loan. I have attached documentation of the deferment I received on
my other federal loan(s).
4.
I receive payment under a federal or state public assistance program, such as Aid to Families with Dependent Children, Supplemental Security
Income, Food Stamps, or state general public assistance. I have attached documentation that I am receiving these benefits.
5. I work full time (30 or more hours per week), and
my Total Monthly Gross Income (TMGI) does not exceed the federal minimum wage, or 100% of the poverty line for a family of two;
*
or
my TMGI is not greater than twice the federal minimum wage or the poverty line for a family of two
*
and when I subtract the amount of payments I
must make on all my federal education loans from my TMGI, the result is not more than the greater of the federal minimum wage or the poverty line
for a family of two; or
the amount of payments I must make on all my federal education loans is at least 20% my TMGI, and the difference between my TMGI and the
amount of payments I must make on my federal education loans is less than 220% of the minimum wage or the poverty line, whichever is greater. To
determine your eligibility for deferment of payments under No. 5, provide the following:
Total monthly gross income (the gross amount you receive from employment and other sources before taxes and other deductions): $_____________
(attach copy of last tax return, and most recent pay statement).
Total monthly payments on federal education loans (list each federal loan lender (school/financial institution), type of federal education loan
(Perkins/NDSL, Stafford, Direct, Consolidation, Health Professions/Nursing, etc.), the amount you borrowed, and the amount of your monthly
payment for each one. Attach copy of monthly bill for each loan.
Lender: Type of Loan: Amount Borrowed Monthly Payment
1. ________________________________ ___________________ $______________ $ __________
2. ________________________________ ___________________ $______________ $ __________
3. ________________________________ ___________________ $______________ $ __________
4. ________________________________ ___________________ $______________ $ __________
5. ________________________________ ___________________ $______________ $ __________
Signature: ________________________________________ Date: __________
*http://aspe.hhs.gov/poverty
Return to: Campus Partners, P.O. Box 2901, Winston-Salem, NC 27102-2901
Hardship.Fm 12/98, revised 01-04 Property of Campus Partners
INCOME & EXPENSES SUMMARY
The following information is requested to determine your eligibility for hardship/unemployment deferment, forbearance, or a revision of your
repayment schedule. The information you provide will remain confidential, however, we reserve the right to use this information if collection efforts
become necessary. We also reserve the right to use a credit report to verify the information you provide.
Name: Account Number(s): ______________________
Address:
Telephone: __________________________ (home) Date of Birth: ______________________
__________________________
(work) Social Security Number: ______________________
1. Marital Status:
o
o
o
o
Single
Married
Widow(er)
Separated/Divorced
2. Number of Dependents:
______
Relationship: ______________ Age: ______
______________ ______
______________ ______
______________ ______
3. Monthly Income from ALL Sources*
:
Gross Monthly Salary/Wages $
________
Spouse's Monthly Salary/Wages $ ________
Child Support $ ________
Alimony/Support $ ________
Unemployment $ ________
Public Assistance $ ________
Social Security/Veteran $ ________
Stocks, Bonds & Investments $
Other: ________________ $ ________
Total Monthly Income
:
$
________
4. Checking Account Balance:
$ ________
5. Savings Account Balance:
$ ________
6. Monthly Expenses
:
Rent/Mortgage: $
________
Utilities: $ ________
Child Care: $
Car Payments: $ ________
Other Vehicle(s) $ ________
Public Transportation: $ ________
Insurance: $ ________
Telephone: $ ________
Cellular Phone/Pager: $ ________
Food: $ ________
Credit Card(s) $ ________
Other Charge Accounts: $ ________
Medical: $ ________
Cable/Satellite TV: $ ________
Entertainment: $ ________
Clothing: $ ________
Dry Cleaning: $ ________
Cleaning/Yard Service: $ ________
Other: ________________________ $ ________
________________________
$ ________
________________________
$ ________
________________________
$ ________
Total Monthly Expenses: $ ________
*Attach a copy of your most recent income tax return AND documentation to substantiate all income and expense entries.
inc & exp sum (7-98) Property of Campus Partners
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Form 2.: APPLICATION FOR HARDSHIPUNEMPLOYMENT DEFERMENT (Brandeis University)

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Completed 23 December 2021

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