Economic Hardship/unemployment Deferment Or Forbearance Request Template Page 3
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48.
My total monthly gross income minus my federal student loan payments is less than the poverty line for my family size.
a.
My Monthly Gross Income Is
$_____________
b.
My Monthly Student Loan payment from 7c
$_____________
c.
Subtract 8b from 8a =
(8a – 8b =)
$_____________
Is the result in Question 8c less than the amount in 5d?
Yes. My total monthly gross income minus loan payments has been below 150% poverty line since _______________.
Send copy of your last two (2) pay stub and evidence of any other income along with evidence of your Title IV Federal Education loan
debt. Include the bill or payment stub from the most recent monthly payment, beginning loan balance(s) and repayment term(s) (e.g.,
disclosure statements or current Repayment schedules).
Continue to Question 12.
No. You do not qualify for an Economic Hardship Deferment. You may still qualify for forbearance. Continue on to Question 9.
9.
I am requesting forbearance because my Federal Student Loan payments are equal to or greater than 20% of my total monthly income.
a.
My
$_____________ x 0.2 =
$_____________
Monthly Gross Income Is
b.
My Monthly Student Loan payment from 7c
$_____________
Is the result from 9a equal to or less than 9b?
Yes. My Title IV loan payments have been equal to or greater than 20% of my monthly gross income since _______________.
Send copy of your last two (2) pay stub and evidence of any other income along with evidence of your title IV Federal education loan debt,
including the bill or payment stub from the most recent monthly payment, beginning loan balance(s) and repayment term(s) (e.g., disclosure
statements or current Repayment schedules).
Continue to Question 12.
No. I am requesting forbearance for other acceptable reason(s). I will attach a letter explaining my case. Please include documents requested
from Questions 5 & 7, along with any other documentation to support your request.
10.
I am currently unable to make scheduled payments due to “Poor Health” (temporarily-total disabled)
Must be completed by your physician.
Patient’s Name: __________________________________
Subjective symptoms:____________________________________
Relationship to Borrower:___________________________
Objective symptoms:_____________________________________
Date when symptoms first appeared:_______________
Diagnosis:_________________________________________________________________
Date accident occurred:__________________________
If needed, please attach a separate sheet of paper.
Treatment
First Visit Date______________________________
Last Visit Date_____________
Frequency of Visit (Weekly, Monthly, Other)______________
Progress
Present Condition:
Recovered____________________
Unchanged___________________
Improved__________
Retrogressed______________________
Is Patient:
Ambulatory___________________
Bed Confined_________________
House Confined_____
Hospital Confined___________________
Extent of Disability
Any Occupation
Regular Occupation
Is patient NOW totally disabled for?
Yes
No
Yes
No
If no, when is or was the patient able to go to work?
_______________
____________________
If yes, will patient be able to resume any work?
Yes
No
Yes
No
Physician Name_______________________________________
Physician License Number_________________________
Address______________________________________________
City__________________________________
State__________________
Zip Code_______________________________
Telephone Number________________________________
Fax Number_____________________________
Attending Physician Signature________________________________________
Date___________________________________
Continue to Question 12
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