Economic Hardship/unemployment Deferment Or Forbearance Request Template
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4Economic Hardship/Unemployment Deferment or Forbearance Request
First Name:
_______________________
Last Name:
_______________________
Middle Initial:
__________________
Student ID/Account #:
___________________________________
Last 4 Digits of SSN:
_______________________
Current Mailing Address:
___________________________________
City, State, Zip Code:
___________________________________
Telephone #:
_______________________
Holder of Loan:
___________________________________
Email:
_______________________
You will be contacted at this email address if this
form is incomplete.
Organization Code:
___________________________________
THIS WORKSHEET MUST BE RETURNED WITH OTHER REQUIRED DOCUMENTS
Select the appropriate response indicating Yes or No and/or enter all requested information for each question. Every question must be completed.
Enter all dates as mm/dd/yy.
1.
Have you been granted a Deferment by another federal student loan program (e.g., Stafford, PLUS or other Perkins
Loan) for the same time period for which you are requesting this deferment?
Yes. That deferment covers the time period starting ____________. Documentation of current loan status is required.
Documentation must include start and end dates of approved deferment. Please complete Questions 7 & 12.
No. Continue to Question 2.
2.
Are you receiving payment under a Federal or State public assistance program, such as Temporary Assistance to Needy Families, Supplemental
Security Income, or Food Stamps?
Yes. I began receiving these benefits on ____________. Send your most recent determination or other verification.
Go directly to Question 12.
No. Continue to Question 3.
3.
Are you unemployed or working less than 30 hours per week?
I am unable to find, but am actively seeking full-time employment. Go directly to Question 11.
I am unable to work due to “Poor Health”. Go directly to Question 10.
No. Continue to Question 4.
4.
Are you working full‐time and earning a total monthly gross income that does not exceed 1256.67 per month, which is equal to someone earning
minimum wage?
NOTE: As of July 24, 2009, the current minimum wage is $7.25. The current hourly minimum wage is available at:
My Monthly Gross Income is: $__________________________
Yes. I have been earning minimum wage or less since _______________.
Send your last two (2) pay stubs and evidence of any other income. If this is not your first request for economic hardship, include a copy of
your most recent Federal Income Tax Return. Continue to Question 12.
No. Continue to Question 5.
To complete the rest of this worksheet you will need information on your monthly gross income from employment and other sources. You may also
need information on your Federal Education Loans. Monthly Gross income is your income before taxes or other deductions, not including spouse’s
income.
5.
Are you working full-time and earning a total monthly gross income that does not exceed 150% of the poverty line?
My Monthly Gross Income is: $__________________________
a.
Family of one
$957.50
b.
Number of Dependents (if any)
__________X $335.00 =
$_____________
c.
Total of 5a +5b =
$_____________
d.
150% of the poverty line
Total from 5c $__________x1.5 =
$_____________
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