1900 West 50
th
Street Marion, IN 46953-9393 indwes.edu
Financial Aid Office, IWU National & Global
800.621.8667 option 4
765.677.2516 765.677.2030 Fax IWUfinaid@indwes.edu
The National Student Loan Data System (NSLDS) indicates that you have one or more student loans discharged because
of a total and permanent disability. Before you can receive additional federal student loans, this form must be
completed and returned to the financial aid office along with a completed Borrower’s Acknowledgement of
Obligation form.
Borrower Information
Name: _______________________________________ ____ ______________________________________________
First M.I. Last
Date of birth: _______/_______/_______ Student ID: _______________________ OR SSN: ______________________
Physician’s Certification
I certify that in my professional medical judgment the pateint/borrower named above is able to engage in
substantial gainful activity.
I cannot certify in my professional medical judgment that the patient/borrower named above is able to engage in
substantial gainful activity.
Date the patient/borrower became able to work and earn wages: _____________________________________________
Physician’s typed or printed name: _____________________________________________________________________
I am a doctor of medicine
osteopathy and legally authorized to practice in the state of: _____________________
Address: _________________________________________________________________________________________
City: _________________________________________________________ State: _________ Zip: _________________
Phone: ______________________________ Physician’s license number: _____________________________________
Physician’s signature: ______________________________________________________ Date: ___________________
General Information
Th
is form is used to obtain a physician’s certification. The purpose is to have a licensed physician certify that the borrower is able to
engage in substantial gainful activity.
Definitions
Substantial Gainful Activity A level of work performed for pay that involves doing significant physical or mental activities or a
combination of both.
Total and Permanent Disability The condition of an individual who: 1) is unable to engage in substantial gainful activity by reason of a
medically determinable physical or mental impairment that can be expected to result in death; has lasted for a continuous period of at
least 60 months; or can be expected to last for a continuous period of at least 60 months; OR 2) has been determined by the
Department of Veterans Affairs (VA) to be unemployable due to a service-connected disability.
Privacy Act Notice
The Privacy Act of 1974 (5 U.S.C. 522a) requires that an agency provide the following notice to each individual whom it asks to supply
information. The authority for collecting the information requested on this form is found in 20 U.S.C. 1087, 42 U.S.C. 209 4k and 22
U.S.C. 2601.
• The principal purpose of this information is to verify the identity of the borrower; determine that the borrower is able to engage
in substantial gainful activity, and in the event it is necessary, to locate the borrower’s certifying physician.
• The routine uses of this information include its disclosure to Federal, State or local agencies, to guaranty agencies, to
educational and financial institutions and to agency contractors for the purpose of verifying the identity of the borrower and the
borrower’s physician; determining that the borrower is able to engage insubstantial gainful activity; investigating possible fraud
and verifying compliance with program regulations. Failure to provide the requested information may result in denial of the
borrower’s new loan request.
• This information is necessary to process requests for new Federal Loan Programs.
CERTIFICATION FORM
NATIONAL & GLOBAL
FINANCIAL AID OFFICE
