Loan Discharge Acknowledgment Form - Kennesaw State University printable pdf download

Loan Discharge Acknowledgment

The National Student Loan Data System (NSLDS) indicates that you have one or more Federal student loans

discharged due to a Total and Permanent Disability. This form MUST be completed and returned to the KSU Office

of Student Financial Aid before your financial aid eligibility may be determined.

Terms and Conditions:

1. If you are granted a final discharge due to total and permanent disability, you are not eligible to receive future loans under

the FFEL, Perkins Loan, or Direct Loan programs or TEACH Grants unless:

•

You sign a statement acknowledging (Section I) that the new loan or TEACH Grant service obligation cannot be

discharged in the future on the basis of any injury or illness present at the time the new loan or TEACH Grant is made,

unless your condition substantially deteriorates so that you are again totally and permanently disabled; and

•

You obtain a certification from a physician that you are able to engage in substantial gainful activity (Section II).

2. If you are granted a conditional discharge based on a total and permanent disability and you request a new FFEL, Perkins

Loan, or Direct Loan program loan or a new TEACH Grant during the conditional discharge period, you are not eligible to

receive the new loan or TEACH Grant unless:

•

You sign a statement acknowledging that neither the previous conditionally discharged TEACH Grant service obligation

or loan(s) nor the new loan or TEACH Grant service obligation can be discharged in the future on the basis of any injury

or illness present when you applied for a total and permanent disability discharge or at the time the new loan or TEACH

Grant is made, unless your condition substantially deteriorates so that you are again totally and permanently disabled

(Section I);

•

You sign a statement acknowledging that the conditionally discharged loan(s) or TEACH Grant service obligation will be

removed from conditional discharge status (Section I);

You obtain a certification from a physician that you are able to engage in substantial gainful activity (Section II); and

•

The Department has removed the conditionally discharged loan(s) or TEACH Grant service obligation from conditional

discharge status.

SECTION I – BORROWER/STUDENT ACKNOWLEDGEMENT (to be completed by the borrower/student)

By signing this form, I, ________________________________________ acknowledge that I have read and understand the terms

(Print Name)

and conditions listed above. I understand that the new loan or TEACH Grant service obligation cannot be discharged in the future

on the basis of any injury or illness present at the time the new loan or TEACH Grant is made, unless my condition substantially

deteriorates so that I am again totally and permanently disabled.

Signature: _______________________________________ Student ID Number: ________________ Date: ________________

SECTION II – PHYSICIAN’S CERTIFICATION STATEMENT (to be completed by certifying Physician)

I certify that the above named person has been examined and in my professional opinion is able to engage in substantial

gainful activity*. Date examined: _____________________

I cannot certify that the above name person is able to engage in substantial gainful activity*.

*Substantial gainful activity is defined as a level of work performed for pay that involves doing significant physical or mental activities or a combination of both.

Comments: _______________________________________________________________________________________________

Name of Physician

Address

Phone Number

Signature

Date

License Number

State of License

DISCHR

Loan Discharge Acknowledgment Form - Kennesaw State University

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