Acs Request For Economic Hardship printable pdf download

Request for Economic Hardship

Name

Account #(s)

Address

City, State, Zip Code

Home Phone ______________________Cell Phone ___________________Work Phone

________________________

E-mail Address

___________________________________________________________________________________________

Must be completed in full and signed in ink by borrower. See definitions on the following page.

Section 1 – Deferment Request –

I meet the qualifications for Economic Hardship Deferment checked below and request deferment of my loan(s) beginning

(MM/DD/YY) ____/____/____

(Maximum time limit is 36 months. Borrowers must reapply every 12 months.)

My total monthly gross income (see Definitions) is $ ___________. Each category requires additional documentation. See the following page.

Qualifications

(1) I have been granted an economic hardship under either the Federal Direct Loan Program or the Federal Family Load Program for the same

time period for which I request this deferment. I must provide documentation of the deferment; OR

(2) I receive payment under a federal or state public assistance program, such as Aid to Families with Dependent Children, Supplemental

Security Income, Food Stamps, or state general public assistance. I must provide documentation of these payments; OR

(3) I do not work full-time, and my monthly gross income (see Definitions) does not exceed twice the larger amount listed in (5) below for my state

and after deducting my total monthly payments for federal education debt (see Definitions) from my monthly gross income, the amount remaining

does not exceed the larger of the amounts in (5) below for my state. (Total monthly payments, adjusted, if necessary, to reflect the minimum 10-

year repayment period, will be calculated by my lender based on information I provide.) I must provide documentation of income and education

debt (see Documentation Requirements).

The total amount I borrowed for all of my federal education loans now in repayment (including the loans for which I am requesting deferment)

is $ ____________ ; OR

(4) I work full-time (see Definitions) and my monthly gross income (see Definitions) is not more than the larger of the amounts listed below for my

state. I must provide documentation of this income (see Documentation Requirements).

Federal Minimum Wage Rate ($6.55 an hour)

$ 1,135.33

150% of Poverty Line:

All States (except Alaska and Hawaii) including the District of Columbia

$1,300.00 plus $450.00 per add’l family member

Alaska

$1,625.00 plus $562.50 per add’l family member

Hawaii

$1,495.00 plus $517.50 per add’l family member

I certify that my family size is: ____________

I understand that I must provide the documentation described on page 2 for any or all of the boxes checked above. I also understand that all principal

and interest will be deferred during the approved period. It is my responsibility to notify the lending institution if my situation changes before the end date

of the deferred period.

I certify that the above information and supporting documentation is true and correct.

Borrowers Signature

Date

Revised 11/2008