Permanent Disability Form - North Carolina State Education printable pdf download

ISCHARGE

PPLICATION

OTAL AND

ERMANENT

ISABILITY

Warning. The SEAA will pursue civil and criminal remedies against any person who knowingly makes a

false statement or misrepresentation on this form or any attached documents.

READ THIS FIRST: This is an application for total and permanent disability discharge of your educational loan funded or

guaranteed by the North Carolina State Education Assistance Authority, (NCSEAA).

To qualify for this discharge a physician must certify in Section 4 of this form that you are unable to work and earn money

because of a condition that is expected to continue indefinitely or result in death. This means that you must be unable to

work in any capacity in any field of work. If you are able to work and earn money in any capacity in any field of work

at the time your physician signs this form, even if only on a limited basis, you are not eligible for this discharge.

This disability standard may differ from disability standards used by other federal agencies (for example, the Social

Security Administration) or other state agencies. A disability determination by another federal or state agency does not

establish your eligibility for this discharge

Section 1: Applicant Information

Name:

SSN:

NCSEAA PID Number:

Address:

Telephone – Home: (

)

City, State, Zip:

Telephone – Other:

(

)

E-mail Address (optional):

Section 2: Instructions for Completing and Submitting This Form

Type or print in dark ink. Enter your name and Social Security Number at the top of pages 2 and 3.

Have a doctor of medicine or osteopathy complete and sign Section 4.

Sign and date the form in Section 3. A representative may sign on your behalf if you are unable to do so because of

your disability.

Make sure that Sections 3 and (if applicable) 4 include all requested information. Incomplete or inaccurate information

may cause your application to be delayed or rejected.

Make sure you return the entire Discharge Application (3 pages) to the address at the bottom of page one.

IMPORTANT: You must submit this form to the NCSEAA within 90 days of the date of your physician’s signature in

Section 4. See Section 3 for address and contact information.

Section 3: Applicant’s Discharge Request, Authorization, Understandings, and Certifications

Before signing, carefully read the entire form, including the instructions on Section 2 and other information on

the following pages.

I request that the NCSEAA discharge my educational loan obligation.

I authorize any physician, hospital, or other institution having records about the disability that is the basis for my

request for a discharge to make information from these records available to the NCSEAA.

I understand the NCSEAA reserves the right to request supplemental information to verify my Discharge Application.

I certify that: (i) I have a total and permanent disability, as defined in Section 5 (ii) I have read and understand the

information on the discharge process, the terms, and conditions for discharge.

Signature of Applicant or Applicant’s Representative

Date (mm-dd-yyyy)

Printed Name of Applicant’s Representative (if applicable)

Address of Applicant’s Representative (if applicable)

Representative’s Relationship to Applicant (if applicable)

Mail the completed discharge application and any attachments to:

If you need help completing this form, call:

NCSEAA – Repayment Services

(919) 549-8614, ext 4654 or

P O Box 14223

(800) 700-1775, ext 4654

RTP, NC 27709

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Permanent Disability Form - North Carolina State Education

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