Check your myClackamas account for all financial aid correspondence and your Award Letter.
Secure submission of documents can be completed in person, by mail, or fax to:
Office of Financial Aid and Scholarships · Roger Rook Hall · 19600 Molalla Avenue, Oregon City, OR 97045
Phone: 503-594-6082 · Fax: 503-722-5864 · e-mail: ·
12/19/18 Rd
(Summer Term 2019 Spring Term 2020)
Student Last Name
Student First Name
Student ID#
Date of Birth
This form is being requested because you have received a Total and Permanent Disability (TPD) discharge for
a student loan(s), as reported in the National Student Loan Database System (NSLDS).
If you do not wish to receive any student loans for this award year, please skip to section B.
A. If you wish to be considered for federal student loans, initial to certify the statements below:
I have read and understand the Borrower Statement below and I understand that a new Borrower
Statement must be submitted each time a new loan is borrowed.
I have attached an original signed physician’s certification on letterhead (must include contact
information) completed by a qualified physician, stating I am employable and able to pay back any new
loans borrowed. -OR-
I already have a physician’s certification on file with Clackamas Community College.
By signing this form, I acknowledge that I have the ability to engage in substantial gainful activity and that any
new federal loans I receive cannot be discharged on the basis of any present impairment unless the condition
deteriorates and I am again totally and permanently disabled.
If a defaulted loan was discharged and then reaffirmed or was conditionally discharged and payment resumed
on it, I understand that I must make satisfactory repayment arrangements before I receive a new loan and/or
grant funds.
Student Signature ______________________________________________ Date ________________
B. Please read and complete if you do not wish to be considered for student loans:
I am not interested in borrowing new federal student loans at Clackamas Community College for the
2019-20 award year. I understand I will not be offered federal student loans but will be offered any state or
federal grants for which I am eligible.
Student Signature ______________________________________________ Date _________________