Certification Form Of Optional Forbearance Or Deferment Status printable pdf download

CERTIFICATION OF OPTIONAL FORBEARANCE OR DEFERMENT STATUS

UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE

INSTITUTIONAL LOANS

Return Form To:

University of Virginia c/o ECSI

100 Global View Drive

Warrendale, PA 15086

Fax: (866) 291-5384

Must Be Submitted: (a) Immediately after receipt of first bill (prior to payment due date)

(b) Annually thereafter for a long as the status is claimed.

List All University Loan Account Numbers Below:

_______________________________________________________________________________________

Full Name of Borrower: __________________________________________________________

______________________________________________________

Address of Borrower:

______________________________________________________

___________________________________

Email address:

Telephone #s:

Home:___________________________ Work:__________________________

Part I REQUEST FOR OPTIONAL FORBEARANCE: principal deferred; interest accrues and is

due monthly (Exception: no interest payments due on Stribling or AMA Loans)

I am requesting optional forbearance because:

_____ I am pursuing advanced professional training in an internship or residency.

_____ I am performing mandatory active duty as a member of the U.S. Armed Forces

(other than service required to repay a Military Health Professions Scholarship.)

_____ I am in fellowship training or a full-time educational program related to my M.D.

_____ Special forbearance approved by the UVA School of Medicine Director of Financial Aid

(Special forbearance monthly payment: $_________ )

Begin Date of above: _____/ _____/ _____ Anticipated End Date of above: _____/ _____/ _____ (12mo increments)

Part II: REQUEST FOR DEFERMENT; principal deferred; no interest accrues

I am requesting full deferment of my loan(s) because:

_____ I am pursuing a degree at the University of Virginia (must be enrolled at least half-time).

_____ I am pursuing a degree at a school other than UVA (must be enrolled at least half time).

_____ Special deferment approved by the UVA School of Medicine Director of Financial Aid

Begin Date of above: _____/ _____/ _____ Anticipated End Date of above: _____/ _____/ _____ (12mo increments)

I agree to notify Campus Partners immediately upon termination of above checked forbearance or

deferment status. I understand that I can make voluntary payments while in forbearance or deferment.

_________________________________

_________________

Borrower Signature

Date

Certification of Above Status By Authorized Official:

(For residency or fellowship, must be Program Director or designee. If a student, must be the registrar or designee.

For special forbearance/deferment above, must be the UVA School of Medicine Director of Financial Aid.)

I certify that the information stated in Part I or Part II above is true.

_____________________________________

_____________________________

_____________

Name of Official

Signature of Official

Date

Name and address of institution represented:

_____________________________________________________________________________

Approved

Disapproved

Date

Signature

rev 04/2016 mb

Certification Form Of Optional Forbearance Or Deferment Status

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