MEDICAL STUDENT LOAN TRUST
MEDICAL INTERNSHIP/RESIDENCY DEFERMENT REQUEST
READ BEFORE COMPLETING FORM. ALL ITEMS RELEVENT TO YOUR REQUEST MUST BE COMPLETED
Email Address
Signature of Authorized Official
Name/Title of Official
Date
Borrower Signature
Date
Return completed form to: American Education Services * P.O. Box 2461* Harrisburg, PA 17105-2461
SECTION 1: BORROWER INFORMATION
SECTION 3: DEFERMENT AGREEMENT
Borrower Account Number
Borrower Name
Address
City
State Zip Code
Telephone Number
Alternate Telephone Number
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.
SECTION 2: MEDICAL INTERNSHIP/RESIDENCY AUTHORIZED OFFICIAL'S CERTIFICATION
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:
Expected Graduation Date:
Name of Institution/Organization
Telephone Number
DOE Code:
Email Address
State Zip Code
My signature indicates that I am an Authorized Official and the certification above is true to the best of my knowledge.
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.
**INCOMPLETE ITEMS MAY BE CAUSE FOR DENIAL**
