Fillable Request For Deferment (Page 2 of 2) in pdf

Case Western Reserve University

FEDERAL PERKINS, NDSL, NSL, HPSL, PCL & LDS Request for Deferment

Part I – To be completed by the Borrower (Complete in INK)

Name:

Social Security Number:

PLEASE CHECK THIS BOX IF NEW ADDRESS

Street Address:

Birth date:

City:

State:

Zip:

Home Phone:

Work Phone:

E-mail address

Lending Institution:

Date Left Lending Institution:

Beginning (mm/dd/yy)-required

Ending (mm/dd/yy)-required

Deferment Request:

(Please refer to your promissory note for specific eligibility requirements)

This is to certify that I am or was:

For Loans Made Before 7/1/1993 Only

At least a half-time student

Serving in an internship or

A working mother of a

residency program

preschooler just entering or re-

A Peace Corps or ACTION

entering the work force

In a Graduate Fellowship Student Program

volunteer

In the National Oceanic &

A full time volunteer in a tax

Atmospheric Corp

Enrolled in a Rehabilitation Training Program

exempt organization

A commissioned officer in US

Type of program_______________________

On full time active duty in the US

Public Health Service Corps

Armed Forces

Parental leave (neither gainfully

Serving in an internship or dentistry residency program

National Guard, Reserves

employed or attending school)

NOTE: IF YOU OR YOUR SPOUSE IS TEMPORARILY TOTALLY DISABLED, YOU ARE SUPPORTING A DISABLED DEPENDENT, OR

YOU ARE IN NEED OF AN UNEMPLOYMENT ECONOMIC HARDSHIP DEFERMENT/FORBEARANCE FOR FINANCIAL OR

UNEMPLOYMENT REASONS, PLEASE CONTACT OUR OFFICE AT THE ADDRESS LISTED BELOW TO OBTAIN FURTHER

INFORMATION.

HEALTH PROFESSIONS STUDENT LOANS, PCL & LDS

NURSING STUDENT LOANS

Pursing a fulltime course of student toward a

Serving an internship or residency

In a nursing program (half-

degree in health professions at any school of

required prior to professional

time/full-time) leading to a

medicine, osteopathy, dentistry, pharmacy,

practice

Type of

baccalaureate or equivalent or

podiatry, optometry or veterinary medicine.

Program____________________________

graduate degree or RN or associate

Participating in a fellowship

degree

Receiving full time advanced professional training

training program

in the field for which the loan was received

On full time active duty in a

Advanced professional training

uniformed service

On fulltime active duty in the

A Peace Corps volunteer

Branch of

Army, Navy, Air Force, Marines,

Service______________________________

Coast Guard, Nat. Oceanic &

A Commissioned officer in US Public Health

Full time educational activity

Atmospheric Admin. Corps. or US

In the National Oceanic & Atmospheric Corp

directly related to the health

Public Health Service Corps.

profession

A Peace Corps volunteer

I HEREBY CLAIM THAT THE ABOVE INFORMATION IS TRUE. I AGREE TO NOTIFY CASE IMMEDIATELY IF MY

STATUS CHANGES. I understand that by requesting a deferment during my original grace period, I am conditionally waiving my rights to said

grace period.

X-Borrower’s Signature (required)__________________________________________________Date (required)___________________

PART II – TO BE COMPLETED BY CERTIFYING OFFICIAL (Required)

I certify that the information state above is correct:

X__________________________________________________________________________________________________________________________

Signature of Authorizing Official

Title

Date

School OPE#

Name and Address of Organization

Deferment Dates

Official Stamp or Seal If no

stamp or seal is available

STATUS:

From:____________

Full time

please provide letterhead

certification.

At least half time

To:______________

Phone Number: _________________

RETURN FORM TO: Case Western Reserve University, Student Loan Department, 10900 Euclid Ave, Cleveland, OH 44106-7041

1-800-273-2455

(216) 368-6911 Fax

Request For Deferment Page 2

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