William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan) Program
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any
accompanying document is subject to penalties that may include fines, imprisonment, or both, under the
U.S. Criminal Code and 20 U.S.C. 1097.
OMB No. 1845-0154
Form Approved
Exp. Date 7/31/2022
Please enter or correct the following information.
Check this box if any of your information has changed.
State Zip Code
Telephone - Primary
Telephone - Alternate
Email (Optional)
Note: As an alternative to completing this section, you may attach separate documentation from a doctor of medicine or
osteopathy legally authorized to practice medicine that includes all of the information requested below.
When will or when did the treatment begin?
When did or when is the treatment expected to end?
Is or was the individual named above scheduled to
receive or receiving cancer treatment in your care?
Has the treatment been completed yet?
I certify, to the best of my knowledge and belief, and in my best medical judgment: that the information that I have
provided is accurate and that I am a doctor of medicine or osteopathy who is legally authorized to practice medicine.
Physician's Name
State Zip Code
Physician's Signature
I request:
A deferment on my eligible loans and forbearance on my ineligible loans during cancer treatment and for 6 months
I want to make interest payments on my ineligible loans during forbearance.
I do not want a forbearance to be applied to my loans which are ineligible for the deferment.
I understand that:
I am not required to make payments of loan principal or interest during my deferment or forbearance.
My deferment or forbearance will begin on the later of September 28, 2018, or when I began receiving treatment.
My loan holder may grant me a forbearance while processing my application or to cover any period of delinquency.
If my treatment is expected to last for longer than 1 year, my loan holder may assume that my treatment will last one
year, but give me the opportunity to extend my deferment based on another certification from my physician.
I am not responsible for paying interest on my loans that receive an interest subsidy during the deferment.
I authorize the entity to which I submit this request and its agents to contact me regarding my request or my loans at any
cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or
prerecorded voice or text messages.
Borrower's Signature
Page 1 of 3
Type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Example: March 14, 2018 = 03-14-2018. Include
your name and account number on any documentation that you are required to submit with this form. If you want to apply
for a deferment on loans that are held by different loan holders, you must submit a separate deferment request to each loan
holder. Return the completed form and any required documentation to the address shown in Section 6.
Capitalization is the addition of unpaid interest to the
principal balance of your loan. Capitalization causes more
interest to accrue over the life of your loan and may cause
your monthly payment amount to increase. Interest never
capitalizes on Perkins Loans. Table 1 (below) provides an
example of the monthly payments and the total amount
repaid for a $30,000 loan. The example loan has a 6%
interest rate and the example forbearance lasts for 12
months and begins when the loan entered repayment. The
example compares the effects of paying the interest as it
accrues or allowing it to capitalize. For the example where
interest is paid, the borrower pays the $1,800 of interest that
accrued during the forbearance and before the forbearance
ends to avoid the impact of interest capitalization.
A deferment is a period during which you are entitled
to postpone repayment of your eligible loans. For the
cancer treatment deferment, with limited exception, you
will not be charged interest on any of your qualifying loans
that receive an interest subsidy. However, you will be
responsible to pay interest on the following loans: Federal
PLUS Loans, Federal Unsubsidized Consolidation Loans,
Federal Supplemental Loans for Students (SLS), National
Direct Student Loans (NDSL), and National Defense Student
Loans (Defense Loans). On loans made under the Perkins
Loan Program, all deferments are followed by a post-
deferment grace period of 6 months, during which time you
are not required to make payments.
An eligible loan is a loan under the Direct Loan Program,
FFEL Program, or Perkins Loan Program which either was
made on or after September 28, 2018 or had entered
repayment on or before September 28, 2018.
The Federal Family Education Loan (FFEL) Program
includes Federal Stafford Loans, Federal PLUS Loans, Federal
Consolidation Loans, and Federal Supplemental Loans for
Students (SLS).
The Federal Perkins Loan (Perkins Loan) Program
includes Federal Perkins Loans, National Direct Student Loans
(NDSL), and National Defense Student Loans (Defense Loans).
A forbearance is a period during which you are allowed
to stop making payments, an extension of time for making
payments, or to make smaller payments. Interest continues to
accrue during forbearance and will capitalize at the
conclusion of the forbearance period if not paid.
The holder of your Direct Loans is the Department. The
holder of your FFEL Program loans may be a lender, guaranty
agency, secondary market, or the Department. The holder of
your Perkins Loans is an institution of higher education or the
Department. Your loan holder may use a servicer to handle
billing and other communications related to your loans.
References to “your loan holder” on this form mean either
your loan holder or your servicer.
The William D. Ford Federal Direct Loan (Direct Loan)
Program includes Federal Direct Stafford/Ford (Direct
Subsidized) Loans, Federal Direct Unsubsidized Stafford/Ford
(Direct Unsubsidized) Loans, Federal Direct PLUS (Direct PLUS)
Loans, and Federal Direct Consolidation (Direct Consolidation)
Table 1. Capitalization Chart
Treatment of Interest with
Loan Amt.
Number of
Interest is paid
$30,000 $0 $30,000 $333 120 $41,767
Interest is capitalized at the
$30,000 $1,800 $31,800 $353 120 $42,365
Interest is capitalized
quarterly and at the end
$30,000 $1,841 $31,841 $354 120 $42,420
Return the completed form and any documentation to:
(If no address is shown, return to your loan holder.)
If you need help completing this form, call:
(If no phone number is shown, call your loan holder.)
Page 2 of 3
Page 3 of 3
To assist program administrators with tracking refunds
and cancellations, disclosures may be made to guaranty
agencies, to financial and educational institutions, or to
federal or state agencies. To provide a standardized method
for educational institutions to efficiently submit student
enrollment statuses, disclosures may be made to guaranty
agencies or to financial and educational institutions. To
counsel you in repayment efforts, disclosures may be made
to guaranty agencies, to financial and educational
institutions, or to federal, state, or local agencies.
In the event of litigation, we may send records to the
Department of Justice, a court, adjudicative body, counsel,
party, or witness if the disclosure is relevant and necessary
to the litigation. If this information, either alone or with
other information, indicates a potential violation of law, we
may send it to the appropriate authority for action. We may
send information to members of Congress if you ask them
to help you with federal student aid questions. In
circumstances involving employment complaints,
grievances, or disciplinary actions, we may disclose relevant
records to adjudicate or investigate the issues. If provided
for by a collective bargaining agreement, we may disclose
records to a labor organization recognized under 5 U.S.C.
Chapter 71. Disclosures may be made to our contractors for
the purpose of performing any programmatic function that
requires disclosure of records. Before making any such
disclosure, we will require the contractor to maintain Privacy
Act safeguards. Disclosures may also be made to qualified
researchers under Privacy Act safeguards.
Paperwork Reduction Notice. According to the
Paperwork Reduction Act of 1995, no persons are required
to respond to a collection of information unless such
collection displays a valid OMB control number. The valid
OMB control number for this information collection is
1845-0154. Public reporting burden for this collection of
information is estimated to average 10 minutes per
response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the
collection of information. The obligation to respond to this
collection is required to obtain a benefit in accordance with
Public Law Number 115-245. If you have comments or
concerns regarding the status of your individual submission
of this form, please contact your loan holder directly (see
Section 7).
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C.
552a) requires that the following notice be provided to you:
The authorities for collecting the requested information
from and about you are §421 et seq. or §451 et seq. of the
Higher Education Act of 1965, as amended (20 U.S.C. 1071 et
seq. or 20 U.S.C. 1087a et seq.) and the authorities for
collecting and using your Social Security Number (SSN) are
§§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and
1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the
William D. Ford Federal Direct Loan (Direct Loan) Program or
Federal Family Education Loan (FFEL) Program and giving us
your SSN are voluntary, but you must provide the requested
information, including your SSN, to participate.
The principal purposes for collecting the information on
this form, including your SSN, are to verify your identity, to
determine your eligibility to receive a loan or a benefit on a
loan (such as a deferment, forbearance, discharge, or
forgiveness) under the Direct Loan or FFEL Programs, to
permit the servicing of your loans, and, if it becomes
necessary, to locate you and to collect and report on your
loans if your loans become delinquent or default. We also
use your SSN as an account identifier and to permit you to
access your account information electronically.
The information in your file may be disclosed, on a case-
by-case basis or under a computer matching program, to
third parties as authorized under routine uses in the
appropriate systems of records notices. The routine uses of
this information include, but are not limited to, its disclosure
to federal, state, or local agencies, to private parties such as
relatives, present and former employers, business and
personal associates, to consumer reporting agencies, to
financial and educational institutions, and to guaranty
agencies in order to verify your identity, to determine your
eligibility to receive a loan or a benefit on a loan, to permit
the servicing or collection of your loans, to enforce the
terms of the loans, to investigate possible fraud and to verify
compliance with federal student financial aid program
regulations, or to locate you if you become delinquent in
your loan payments or if you default. To provide default rate
calculations, disclosures may be made to guaranty agencies,
to financial and educational institutions, or to state
agencies. To provide financial aid history information,
disclosures may be made to educational institutions.