DIRECTIONS: Complete Section 1 and have your physician fax the completed form to the Office of
Financial Aid at Purdue University Northwest.
SECTION 1: To be Completed by Borrower
Name of Borrower: ___________________________ Borrower’s
PUID: __________________
Consent for Release of Information: I authorize any physician, hospital or other institution having
records pertaining to the disability for which I previously received cancellation of my loan(s) to make
information from such records available to Purdue University Northwest.
Acknowledgement of Inability to Cancel Loan: I hereby acknowledge that any Federal Family
Education Loan and/or William D. Ford Federal Direct Loan(s) which I receive subsequent to this statement
cannot be discharged in the future on the basis of any injury or illness present at the time the new loan is made,
unless my condition substantially deteriorates so that I am again totally and permanently disabled.
Falsified documentation will result in an immediate denial of your appeal. Future appeals may be denied as
well. In addition, your name will be referred to the Dean of Students Office at Purdue University Northwest.
Student Signature: _______________________________________ Date: ______________
SECTION 2: To be Completed by Certifying Physician
(Please Fax Completed Form to Purdue Northwest
Instructions to Physician: The borrower for which you are completing this certification has previously had
loans discharged due to total and permanent disability. At the time of that discharge, a physician certified that the
borrower was totally and permanently disabled.
You are asked to certify that the borrower named above is abl
e to engage in substantial gainful activity. Effective
July 1, 2012, the U.S. Department of Education defines “substantial gainful activity” as, “a level of work performed
for pay or profit that involves doing significant physical or mental activity, or both.”
Physician C
ertification of Borrower’s Ability to Engage in Substantial Activity
I certify in my best professional judgment (borrower) _________________________________________
is able to engage in substantial activity as defined by the U.S. Department of Education.
Signature of Physician (M.D. or D.O.): ___________________________________________________
I am Legally Authorized to Practice in the State of _____________________ Today’s Date: ___/___/____
Type or Print Physician’s Name
: ____________________________________________________________________
Address: __________________________________________________________________
Office and Fax Number: _____________________________________________________
Office Use Only – RRAAREQ: ___DRCERT (R)
Hammond Campus
2200 169th Street * Hammond, IN 46323
(21 9)))) 989-2301 * FAX: (219) 989-2141
Westville Campus
1401 S. U.S. Hwy. 421 * Westville, IN 46391
(219) 785-5460 * FAX: (219) 785-5653
Toll-Free: 1-855-608-4600