Permanent Disability Form - North Carolina State Education (Page 3 of 3) in pdf

Permanent Disability Form - North Carolina State Education Page 3

Applicant Name:

Applicant SSN:

Physician’s Certification

I certify that, in my best professional judgment, the applicant identified above is unable to work and earn

money in any capacity in any field of work because of an injury or illness that is expected to continue

indefinitely or result in death.

I understand that an applicant who is currently able or who is expected to be able to work and earn money in

any capacity in any field of work, even on a limited basis, does not have a total and permanent disability as

defined on this form.

□

I am a doctor of (please, check one)

medicine

osteopathy/osteopathic medicine. I am legally

authorized to practice in the state of _________________________________, and my professional license

number is ______________________ (subject to verification through state records).

Note: Chiropractors, herbalists, physician assistants, registered nurses, or other allied health professionals are

not eligible to certify total and permanent loan discharge applications. Applications certified by any other than a

licensed M.D. or D.O. will be returned.

Physician’s Signature (a signature stamp is not acceptable)

Date (mm-dd-yyyy)

Printed Name of Physician (first, middle initial, last name)

Address

City, State, Zip

(

)

(

)

Telephone

Fax

E-mail Address (optional)

Section 5: Definitions

If you have a total and permanent disability, this means that you are unable to work and earn money because of an

injury or illness that is expected to continue indefinitely or result in death. Note: This disability standard may differ from

disability standards used by other agencies (federal or state). A disability determination by another federal or state

agency does not establish your eligibility for a discharge of your loan(s) due to a total and permanent disability.

A final discharge of a loan due to a total and permanent disability cancels your obligation (and, if applicable, an

endorser’s obligation) to repay the remaining balance on your NCSEAA funded or guaranteed loan obligation.

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Permanent Disability Form - North Carolina State Education Page 3