SouthEast Bank and ESA Internship Residency Deferment Request
READ BEFORE COMPLETING FORM. ALL ITEMS RELEVENT TO YOUR REQUEST MUST BE COMPLETED
**INCOMPLETE ITEMS MAY BE CAUSE FOR DENIAL**
SECTION 1: BORROWER INFORMATION
Borrower Account Number:
Borrower Name:
Address:
City:
Zip:
Email Address:
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: 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.
Institution/Organization Name:
DOE Code: Telephone Number:
Address:
My signature indicates that I am an Authorized Official and the certification above is true to the best of my knowledge.
Signature of Authorized Official Name/Title of Official
Date
SECTION 3: DEFERMENT AGREEMENT
I meet the qualifications as stated in the cover letter for 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.
Borrower Signature
Return completed form to: American Education Services *P.O. Box 2461* Harrisburg, PA 17105-2461
or Fax 717-720-3916
Telephone Number: Mobile:
State:
Program Begin Date:
Program End Date:
Expected Graduation Date:
Date
State:
Zip:
Records Code: APFG/FBSEB
Revision Date: 06/2019
