Nm Student Loans Nurses For New Mexico - Request For Interest Benefit Form
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2NM Student Loans
Nurses for New Mexico
Request for Interest Benefit
Name________________________________________ Social Security Number _____________________________________
Street Address__________________________________________________________________________________________
City ______________________________________________________ State ______________________ Zip______________
Home Phone_________________Work Phone_________________ Date of Birth ___________________________________
Last School Attended ___________________________________________________________________________________
Graduation Date ______________________________________ Email ____________________________________________
I certify that I work/worked full time as a Nurse in New Mexico from ________________________ to___________________
mm/dd/yy
mm/dd/yy
at ___________________________________________________________________________________________________
Organization Name and Address
I certify I have read and understand the conditions for eligibility on the reverse side of this request and meet all qualifications
for the interest benefit on my loan(s). I understand I must submit my request and certification yearly, as long as I am eligible,
in order to receive the interest benefit. I understand that I am required to notify NM Student Loans of any changes to my
eligibility status.
________________________________________ ____________________________
_____________________________
Borrower’s Signature
Nursing License Number & State
Date
MUST BE COMPLETED BY CERTIFYING OFFICIAL
I certify the information above is correct.
______________________________________________
_________________________
______________
Signature of Authorizing Official
Title
Date
______________________________________________
Employment Dates of Applicant
Printed Name
____________________/_____________________
______________________________________________
From: mm/dd/yy
To: mm/dd/yy
Organization Address
_________________________________________
______________________________________________
Job Title
City/State/Zip
______________________________________________
Employment Status:
Full Time
Part Time
Phone
______________________________________________
Email
Return Form To:
New Mexico Student Loans
PO Box 27020
Albuquerque, NM 87125-7020
NMEAF DBA NM Student Loans
1-800-279-5063, ext. 1472
Fax: 505-345-7269
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