Economic Hardship/unemployment Deferment Or Forbearance Request Template Page 4
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411.
If you are unemployed or seeking full- • ‐ t ime employment, complete the following.
I became unemployed or working under 30 hours a week on _______________ and have registered with the following public
a.
or private employment agency. Agency seal or stamp is required.
If registered with an online agency, attach online application history from the last three (3) three months
Name of Employment Agency____________________________________________
Telephone Number_________________________
Agency Address (City, State, Zip Code)______________________________________
Place Official Seal or Stamp Here
(Notary seal not acceptable)
_____________________________________
b.
I became unemployed on _______________.
Attach proof of unemployment benefits, from a State Agency. If this isn’t your first request, you must also complete section (A).
c.
I became unemployed or working under 30 hours a week on _______________. In the last six months, I have made attempts to secure
full time employment at the following three firms. If this is not your first request, you must also complete section (A).
Complete all the information requested for each of the three firms.
1.
Name of Firm______________________________________________________________________
Address___________________________________________________________________________
Telephone Number________________________________________
Contact (Name &Title)____________________________
2.
Name of Firm______________________________________________________________________
Address___________________________________________________________________________
Telephone Number_______________________________
Contact (Name &Title) _____________________________
3.
Name of Firm______________________________________________________________________
Address___________________________________________________________________________
Telephone Number_______________________________
Contact (Name &Title) _____________________________
Continue on to Question 12.
12.
I understand that: (1) This request will not be granted, unless all applicable sections of this form are completed and requested
documents are submitted; (2) You may be granted a forbearance of your loans that are not eligible for deferment. (3) All final decision
regarding my deferment/forbearance eligibility will be made in accordance with applicable Federal Regulations. I certify that: (1) The
information provided above is true and correct; (2) I will provide additional documentation, as required, to the Student Loan Office or
ECSI to support my continued deferment/forbearance status; (3) I will notify My Student Loan Office or ECSI Immediately when the
condition(s) that qualified me for this deferment/forbearance ends; And (4) I have read, understand, and meet the terms and conditions
of the deferment/forbearance for which I have applied.
If, approved for forbearance, I understand that interest will continue to accrue monthly, and I wish to pay this interest:
At the end of the approved forbearance.
Monthly as it accrues.
I authorize ECSI Federal Perkins Loan Servicer (ECSI) and its respective agents and contractors to contact me regarding any account
Yes___ No___
being serviced or collected by ECSI, including repayment of any account, at my current or any future telephone number (cellular or
otherwise) or other wireless device that is assigned to me or where I am an authorized user of the number/device using automated
telephone dialing equipment or artificial or pre-recorded voice or text messages.
You will be notified via the email provided on page 1 if your request is denied.
Signature__________________________________________________
Date_____________________________
Address___________________________________________________
Home Phone_________________________
City, State, Zip Code__________________________________________
Cell Phone____________________________
ECSI Federal Perkins Loan Servicer
P.O. Box 1079
Mail form to:
Wexford, PA 15090
For Office Use Only:
Approved:
Denied:
Processed By:
Date:
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