UNEM
UNEMPLOYMENT DEFERMENT REQUEST
OMB No. 1845-0011
Form Approved
William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Exp. Date 8/31/2021
LS004-XDFR
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan) Program
WARNING
: Any person who knowingly makes a false statement or misrepresentation on this form or on
any accompanying document is subject to penalties that may include fines, imprisonment, or both, under
the U.S. Criminal Code and 20 U.S.C. 1097.
SECTION 1: BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
City
State Zip Code
Telephone - Primary
Telephone - Alternate
Email (Optional)
SECTION 2: BORROWER DETERMINATION OF DEFERMENT ELIGIBILITY
Carefully read the entire form before completing it. Complete Section 2 in its entirety. Maximum eligibility is 36
months per loan program.
1.
Are you receiving unemployment benefits?
4.
Is this an extension of a previously granted
Unemployment Deferment?
If you answer yes, you must attach
Yes - Continue to Item 5.
documentation of your eligibility for these benefits
which:
No - Skip to Item 6.
Includes your name, address, and Social Security
5.
Have you made at least six diligent attempts to find
Number; and
full-time employment in the most recent 6 months?
Yes - Continue to Item 6.
benefits for the period of time for which you are
Shows that you are eligible to receive the
No - You are not eligible for this deferment
requesting a deferment.
unless you are a Perkins Loan borrower. If you
Yes - Skip to Section 3.
are a Perkins Loan borrower, continue to Item 6.
No - Continue to Item 2.
6.
Is there a public or private employment agency
within 50 miles of your current address?
2.
Are you diligently seeking but unable to find full-
School placement offices, temporary
time employment (see Section 5) in the United
employment agencies, and Web sites that allow
States?
users to search or apply for employment do not
Yes - Continue to Item 3.
qualify.
No - You are not eligible for this deferment.
Yes - Continue to Item 7.
No - Skip to Section 3.
3.
Have you rejected offers of full-time employment in
the United States in any field or at any salary or
7.
Have you registered with the public or private
responsibility level because you were overqualified?
employment agency?
Yes - You are not eligible for this deferment
Yes - Continue to Section 3.
unless you are a Perkins Loan borrower. If you
No - You are not eligible for this deferment
are a Perkins Loan borrower, continue to Item 4.
unless you are a Perkins Loan borrower. If you
No - Continue to Item 4.
are a Perkins Loan borrower, continue to
Section 3.
Page 1 of 4
Borrower Name Borrower SSN
SECTION 3: BORROWER REQUESTS, UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION
I request:
To defer repayment of my loans for the period during which I meet the eligibility criteria in Section 2.
That my deferment begin on the date that I became unemployed or began working less than full time, which was:
unless I provide a later date here:
.
If checked, to make interest payments during deferment.
I understand that:
I am not required to make payments of loan principal or interest during my deferment.
My deferment will begin on the later of the date I became eligible for the deferment or the date I requested.
However, if this is my first request for the deferment for my current period of unemployment and I am not providing
documentation of unemployment benefits, my deferment will begin no more than 6 months before my request.
If I am a Perkins Loan borrower, I will receive a 6-month post-deferment grace period beginning on the date I no
longer qualify for the deferment.
If I am a Direct Loan or FFEL Program borrower, my deferment will end on the earlier of the date I exhaust my
maximum eligibility for the deferment, 6 months from the date my deferment begins, or on the date I am no longer
eligible for the deferment for another reason.
If I am a Perkins Loan borrower, my deferment will end on the earlier of the date I exhaust my maximum eligibility for
the deferment, 12 months from the date my deferment begins, or on the date I am no longer eligible for the
deferment for another reason.
My loan holder may grant me a forbearance while processing my form or to cover any period of delinquency that
exists when I submit my form.
Unpaid interest may capitalize on my loan during or at the expiration of my deferment or forbearance, but interest
never capitalizes on a Perkins Loan.
Instead of deferment, I may be eligible for a repayment plan that determines my monthly payment amount based on
my income and that I can visit StudentAid.gov/IDR for more information.
I certify that:
The information I have provided on this form is true and correct.
I will provide additional documentation to my loan holder, as required, to support my deferment eligibility.
I will notify my loan holder immediately when my eligibility for the deferment ends.
I have read, understand, and meet the eligibility requirements in Section 2.
I authorize
the entity to which I submit this request and its agents to contact me regarding my request or my loans at any
cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or
prerecorded voice or text messages.
Date
Borrower's Signature
SECTION 4: INSTRUCTIONS FOR COMPLETING THE DEFERMENT REQUEST
Type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Example: March 14, 2019 = 03-14-2019. Include
your name and account number on any documentation that you are required to submit with this form. If you want to apply
for a deferment on loans that are held by different loan holders, you must submit a separate deferment request to each loan
holder. If you have loans made jointly (as co-makers), both borrowers must individually meet the requirements for a
deferment and each of you must submit a separate deferment request.
Return the completed form and any required
documentation to the address shown in Section 6.
Page 2 of 4
(If no phone number is shown, call your loan holder.)
If you need help completing this form, call:
U.S. Department of Education FedLoan Servicing
P.O. Box 69184
Harrisburg, PA 17106-9184
Fax: 717-720-1628
Or sign in to your account at MyFedLoan.org to upload your document
Domestic: 800-699-2908
International: 717-720-1985
TTY: Dial 711
Or visit
MyFedLoan.org
SECTION 5: DEFINITIONS
The
William D. Ford Federal Direct Loan (Direct Loan)
Program
includes Federal Direct Stafford/Ford (Direct
Subsidized) Loans, Federal Direct Unsubsidized Stafford/
Ford (Direct Unsubsidized) Loans, Federal Direct PLUS
(Direct PLUS) Loans, and Federal Direct Consolidation
(Direct Consolidation) Loans.
The
Federal Family Education Loan (FFEL) Program
includes Federal Stafford Loans, Federal PLUS Loans, Federal
Consolidation Loans, and Federal Supplemental Loans for
Students (SLS).
The
Federal Perkins Loan (Perkins Loan) Program
includes Federal Perkins Loans, National Direct Student
Loans (NDSL), and National Defense Student Loans (Defense
Loans).
Capitalization
is the addition of unpaid interest to the
principal balance of your loan. Capitalization causes more
interest to accrue over the life of your loan and may cause
your monthly payment amount to increase. Interest never
capitalizes on Perkins Loans. Table 1 (below) provides an
example of the monthly payments and the total amount
repaid for a $30,000 unsubsidized loan. The example loan
has a 6% interest rate and the example deferment or
forbearance lasts for 12 months and begins when the loan
entered repayment. The example compares the effects of
paying the interest as it accrues or allowing it to capitalize.
A
co-maker
is one of the two individuals who are joint
borrowers on a Direct or Federal Consolidation Loan or a
Federal PLUS Loan. Both co-makers are equally responsible
for repaying the full amount of the loan.
A
deferment
is a period during which you are entitled
to postpone repayment of your loans. Interest is not
generally charged to you during a deferment on your
subsidized loans. Interest is always charged to you during a
deferment on your unsubsidized loans.
Table 1. Capitalization Chart
On loans made under the Perkins Loan Program, all
deferments are followed by a post-deferment grace period
of 6 months, during which time you are not required to
make payments.
A
forbearance
is a period during which you are
permitted to postpone making payments temporarily,
allowed an extension of time for making payments, or
temporarily allowed to make smaller payments than
scheduled.
Full-time employment
means working 30 or more
hours a week in a position expected to last at least 3
consecutive months.
The
holder
of your Direct Loans is the Department. The
holder of your FFEL Program loans may be a lender,
guaranty agency, secondary market, or the Department. The
holder of your Perkins Loans is an institution of higher
education or the Department. Your loan holder may use a
servicer to handle billing and other communications related
to your loans. References to “your loan holder” on this form
mean either your loan holder or your servicer.
A
subsidized loan
is a Direct Subsidized Loan, a Direct
Subsidized Consolidation Loan, a Federal Subsidized
Stafford Loan, portions of some Federal Consolidation
Loans, a Federal Perkins Loan, an NDSL, and a Defense Loan.
An
unsubsidized loan
is a Direct Unsubsidized Loan, a
Direct Unsubsidized Consolidation Loan, a Direct PLUS
Loan, a Federal Unsubsidized Stafford Loan, a Federal PLUS
Loan, a Federal SLS, and portions of some Federal
Consolidation Loans.
The
United States
includes any US State, the District of
Columbia, Puerto Rico, American Samoa, Guam, the Virgin
Islands, the Northern Mariana Islands, the Marshall Islands,
Micronesia, Palau, and US military bases and embassies.
Treatment of Interest with
Deferment/Forbearance
Loan
Amount
Capitalized
Interest
Outstanding
Principal
Monthly
Payment
Number of
Payments
Total
Repaid
Interest is paid
$30,000 $0 $30,000 $333 120 $41,767
Interest is capitalized at the
end
$30,000 $1,800 $31,800 $353 120 $42,365
Interest is capitalized
quarterly and at the end
$30,000 $1,841 $31,841 $354 120 $42,420
SECTION 6: WHERE TO SEND THE COMPLETED DEFERMENT REQUEST
Return the completed form and any documentation to:
(If no address is shown, return to your loan holder.)
Page 3 of 4
SECTION 7: IMPORTANT NOTICES
Privacy Act Notice.
The Privacy Act of 1974 (5 U.S.C.
552a) requires that the following notice be provided to you:
The authorities for collecting the requested information
from and about you are §421 et seq., §451 et seq., or §461 et
seq. of the Higher Education Act of 1965, as amended (20
U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., or 20 U.S.C.
1087aa et seq.) and the authorities for collecting and using
your Social Security Number (SSN) are §§428B(f) and 484(a)
(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31
U.S.C. 7701(b). Participating in the William D. Ford Federal
Direct Loan (Direct Loan) Program, Federal Family Education
Loan (FFEL) Program, or Federal Perkins Loan (Perkins Loan)
Program and giving us your SSN are voluntary, but you must
provide the requested information, including your SSN, to
participate.
The principal purposes for collecting the information on
this form, including your SSN, are to verify your identity, to
determine your eligibility to receive a loan or a benefit on a
loan (such as a deferment, forbearance, discharge, or
forgiveness) under the Direct Loan, FFEL, or Federal Perkins
Loan Programs, to permit the servicing of your loans, and, if
it becomes necessary, to locate you and to collect and
report on your loans if your loans become delinquent or
default. We also use your SSN as an account identifier and to
permit you to access your account information
electronically.
The information in your file may be disclosed, on a case-
by-case basis or under a computer matching program, to
third parties as authorized under routine uses in the
appropriate systems of records notices. The routine uses of
this information include, but are not limited to, its disclosure
to federal, state, or local agencies, to private parties such as
relatives, present and former employers, business and
personal associates, to consumer reporting agencies, to
financial and educational institutions, and to guaranty
agencies in order to verify your identity, to determine your
eligibility to receive a loan or a benefit on a loan, to permit
the servicing or collection of your loans, to enforce the
terms of the loans, to investigate possible fraud and to verify
compliance with federal student financial aid program
regulations, or to locate you if you become delinquent in
your loan payments or if you default. To provide default rate
calculations, disclosures may be made to guaranty agencies,
to financial and educational institutions, or to state
agencies. To provide financial aid history information,
disclosures may be made to educational institutions.
To assist program administrators with tracking refunds
and cancellations, disclosures may be made to guaranty
agencies, to financial and educational institutions, or to
federal or state agencies. To provide a standardized method
for educational institutions to efficiently submit student
enrollment statuses, disclosures may be made to guaranty
agencies or to financial and educational institutions. To
counsel you in repayment efforts, disclosures may be made
to guaranty agencies, to financial and educational
institutions, or to federal, state, or local agencies.
In the event of litigation, we may send records to the
Department of Justice, a court, adjudicative body, counsel,
party, or witness if the disclosure is relevant and necessary
to the litigation. If this information, either alone or with
other information, indicates a potential violation of law, we
may send it to the appropriate authority for action. We may
send information to members of Congress if you ask them
to help you with federal student aid questions. In
circumstances involving employment complaints,
grievances, or disciplinary actions, we may disclose relevant
records to adjudicate or investigate the issues. If provided
for by a collective bargaining agreement, we may disclose
records to a labor organization recognized under 5 U.S.C.
Chapter 71. Disclosures may be made to our contractors for
the purpose of performing any programmatic function that
requires disclosure of records. Before making any such
disclosure, we will require the contractor to maintain Privacy
Act safeguards. Disclosures may also be made to qualified
researchers under Privacy Act safeguards.
Paperwork Reduction Notice.
According to the
Paperwork Reduction Act of 1995, no persons are required
to respond to a collection of information unless such
collection displays a valid OMB control number. The valid
OMB control number for this information collection is
1845-0011. Public reporting burden for this collection of
information is estimated to average 10 minutes per
response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the
collection of information. The obligation to respond to this
collection is required to obtain a benefit in accordance with
34 CFR 674.34, 674.35, 674.36, 674.37, 682.210, or 685.204.
If you have comments or concerns regarding the
status of your individual submission of this form, please
contact your loan holder directly (see Section 6).
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