Student Loan Deferment Form - University Of Maryland

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Student Loan Deferment Form
PART 1
To Be Completed by the Borrower
(Please Print)
Full Name: _______________________________________________________________________________________
SSN last 4: XXX-XX-__________________ Email: ________________________________________________________
Mailing Address: __________________________________________________________________________________
Home Phone: ___________________ Cell Phone: ______________________ Work Phone: _____________________
PART 1.2
Period of Request
Missing information & altered dates will not be accepted
Beginning Date: (mm/dd/yy)
Ending Date: (mm/dd/yy)
Anticipated Separation Date: (mm/dd/yy)
____/____/____
____/____/____
____/____/____
PART 1.3
Reason for Request
This is to certify that I am or was: (check all that apply)
Federal Perkins, Perkins or NDSL:
Health Professions: UM-Institutional:
Nursing:
A Peace Corps, VISTA or ACTION volunteer
A Peace Corps volunteer
A Peace Corps volunteer
In the National Oceanic/Atmospheric
On full-time active duty in a uniform service
Active duty in the uniformed services
Administration
Participating in a fellowship training program
Full-time or half-time enrollment in a
An officer in the US Public Health Services
Serving an internship or residency
collegiate nursing program leading to a
An officer in the US Public Health Service
baccalaureate degree/graduate
A full-time volunteer in a tax exempt
Commissioned Corps
degree in nursing
organization
Receiving full-time advanced training in the field
Pursing advanced professional training
for which the loan was received
in nursing, or training to become a
Pursing a full-time course of study towards a
nurse anesthetist
degree in a health profession school within the
applicable grace period
PART 1.4
Declaration
I hereby claim that the above information is true and accurate. I agree to notify University of Maryland immediately upon termination of or change
in my claiming status. I further declare that if, for any reason, I am unable to complete a year of service for which I have requested deferment
benefits, I will begin repayment of my loan.
Borrower’s Signature: _______________________________________________________ Date: _________________________________________
Part 2
To Be Completed by Certifying Official -
**school certification section requires the Federal School Code
I certify that the information stated above is correct: ______________________________________________ Date: _________________________
(Authorizing Signature)
Printed Name: _____________________________________________________ **Federal School Code: __________________________________
Institution Name: _______________________________________________________________________
Official Seal or Stamp
Address: ______________________________________________________________________________
Telephone: ____________________________________________________________________________
*IF SEAL OR STAMP IS UNAVAILABLE, PLEASE PROVIDE LETTERHEAD CERTIFICATION*
University of Maryland-Baltimore (X7)
Return Forms To:
c/o Heartland ECSI
P.O. Box 1278
If you have any questions, please visit us at https://heartland.ecsi.net
or call us toll-free at 888.549.3274.
Wexford, PA 15090
FOR ECSI USE ONLY
Approved _____ Disapproved _____ Official Name ______________________________________ Date _____________

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