Borrower Account Number:
Borrower Name:
Address:
City:
Zip:
Telephone Number:
Alternate Telephone Number:
State:
PRIVATE EDUCATION LOAN
Email Address:
SECTION 1: BORROWER INFORMATION
SECTION 2: AUTHORIZED OFFICIAL'S CERTIFICATION
SCHOOL
Date
Borrower Signature
SECTION 3: DEFERMENT AGREEMENT
Return completed form to: American Education Services * P.O. Box 2461 * Harrisburg, PA 17105-2461 By fax: (717) 720-3916
REQUEST FOR DEFERMENT
READ BEFORE COMPLETING FORM. ALL ITEMS RELEVANT TO YOUR REQUEST MUST BE COMPLETED
**INCOMPLETE ITEMS MAY BE CAUSE FOR DENIAL**
Employer Name:
Employer 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 autodailer or
similiar 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 deferment request.
Full Time
Half Time
MEDICAL INTERNSHIP/RESIDENCY
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:
Institution/Organization Name:
DOE Code:
Telephone Number:
Address:
City:
Zip:
State:
My signature indicates that I am an Authorized Official and the certification above is true to the best of my knowledge.
Name/ Title of Official
Signature of Authorized Official
Date
I meet the qualifications as stated in the cover letter for the deferment type checked above and request my lender/servicer to
defer repayment of my eligible education 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 credit agreement. I understand that in accordance with the
terms of my original credit agreement, I may be required to pay accrued interest during periods of deferment. I understand that,
should my situation under which I applied for deferment change, I must notify my lender/servicer immediately.
