Fillable Application For Education Loan Form printable pdf download

CGMA –

APPLICATION FOR EDUCATION LOAN

Instructions for completion: All applicants are to complete Sections A, B (if applicable) and C, read Section D and sign the application for

assistance. Return the completed, signed application along with supporting documentation to a local CGMA Representative for processing.

Section A – CGMA CLIENT INFORMATION

1. Name: Last

First

2. Rank/Rate/Grade

3. Social Security #

4. Home Phone #

(

)

5. Home Address: Street

Apt. No.

City

State

Zip Code

6. Status: (Indicate prior status if CGMA Member is deceased)

Active Duty

Retired

Civilian

Reserve

Auxiliary

CGES

PHS

Other __________

7. Present Unit: (if applicable)

OPFAC #

8. Work Phone #

(

)

9. Date of Birth (MM/DD/YYYY)

10. Years of Service

11. Anticipated date of Separation (MM/DD/YYYY)

12. Date Retired (MM/DD/YY)

Section B – STUDENT INFORMATION

(To be completed if not the client.)

13. Name: Last

First

14. Social Security #

15. Relationship to Client

Section C – EDUCATION LOAN ASSISTANCE REQUESTED

(may not exceed $3,000)

16. Type of Assistance Requested

17. Total Amount of Assistance Requested

18. Requested Monthly Repayment Amount

Interest-Free Education Loan Only

Spending plan:

Tuition

$__________

Fees

$__________

Other Expenses $____________

Transportation Expenses

$__________

Course Materials

$__________

Explain ____________________________

Other Funding Sources:

Student Loans

$_____________

Scholarship Grants

$_____________

(Provided specifically to offset the above costs.)

Attach the following documents:

The student’s proof of enrollment (e.g. a letter from the Registrar’s office)

Documented Cost Estimates (e.g. tuition/fees list, course syllabus listing required course materials, etc.)

When mailing application, a photocopy of the client’s valid Coast Guard ID card (both sides, clearly legible)

(If the client is deceased, a copy of spouse’s/legal guardian’s valid ID must be provided.)

Section D – APPLICANT'S CERTIFICATION

Everything that I have stated in this application and attached documents is correct to the best of my knowledge. I understand that you will retain this

application whether or not it is approved. You are authorized to check the facts surrounding this request including my credit and employment history. I

understand that any misstatement of fact is grounds for denial of this request. I understand and agree that my signature constitutes voluntary consent to

collection of the debt, or any remainder thereof, from my final pay upon separation or retirement from the armed forces. I understand that I am

responsible for any unpaid balance and that any delinquent unpaid balance may be referred to a collection agency and may affect my credit.

I hereby authorize the U.S. Coast Guard to supply CGMA with any requested information contained in my official Coast Guard personnel and pay files in

connection with this assistance. I further authorize the U.S. Coast Guard, or any agency, to supply my latest home address to CGMA whenever

requested. I understand that CGMA is an independent private entity, not part of the U.S. Government. This application form, therefore, is not subject to

the Privacy Act (5 U.S.C. 552a). Information provided on this application, in some cases, may be provided by CGMA to the Coast Guard when deemed

necessary. This form, with attachments, will be placed in the CGMA Representative's unit file.

Applicant’s Signature

Date

CGMA Form 11 (Oct 2014)

CGMA-HQ (800) 881-2462