Form 519 Certification of Deferment

OMB NO: 0915-0044

HRSA519 CERTIFICATION OF DEFERMENT EXP DATE: 03/31/09

_________________________________________________________________________________________________________________

HEALTH PROFESSIONS STUDENT LOAN (HPSL), PRIMARY CARE LOAN (PCL), EXCEPTIONAL FINANCIAL NEED (EFN) SCHOLARSHIPS, FINANCIAL ASSISTANCE FOR DISADVANTAGED HEALTH PROFESSIONS STUDENTS (FADHPS), LOANS FOR DISADVANTAGED STUDENTS (LDS)

AND NURSING STUDENT LOAN (NSL) PROGRAMS _____________________________________________________________________________________________________________________________

INSTRUCTIONS: You as a borrower of a HPSL, PCL, LDS, or NSL, are responsible for the completion and return of this form to the institution from which you received loans. If you fail to submit this form to your school by the payment due date, your school is required to consider your loan past due, and must take actions to collect as required by program regulations, including the use of collection agents, credit bureaus, and litigation.

To request deferment of repayment on your HPSL, PCL, LDS, or NSL, this form must be filed with the school which made the loan at each of the following times:

1. when your first repayment installation is due.,

2. annually thereafter as long as you are eligible for such deferment and

3. when you cease to be in eligible deferment status.

Recipients of EFN or FADHPS scholarships with a primary care service obligation must complete this form annually during residency training to notify the school of their

training activities.

A copy of the completed form should be retained for your own record.

NAME AND ADDRESS OF SCHOOL FROM WHICH FUNDS WERE RECEIVED:

NAME AND ADDRESS OF LOAN/SCHOLARSHIP RECIPIENT:

PART 1 – SIGNATURE OF LOAN/SCHOLARSHIP RECIPIENT

I request deferment of repayment of principal and interest on my (Check all that apply):

___Health Professions Student Loan(s)___Primary Care Loan(s)___Loans for Disadvantaged Students __Nursing Student Loan(s) for the period

indicated under___A1___A2___B___C1___C2___D or___E below.

I received ___EFN___FADHPS funds and am notifying the school of my residency training activities.

I further agree to notify the school from which I received assistance immediately upon termination of my status as indicated below.

____________________________________________________

SIGNATURE OF BORROWER: DATE

PART II: REQUEST FOR DEFERMENT OF REPAYMENT – To be completed by borrower if he/she:

A. 1. For Health Professions Student Loan and Loans for Disadvantaged Students Borrowers:

Pursues advanced professional training, including internships and residencies or participates in a fellowship training program

or full-time educational activity, as defined by regulations of the Secretary of Health and Human Services.

2. For Nursing Student Loan Borrowers:

Pursues a full-time or part-time course of study at a collegiate school of nursing leading to a baccalaureate degree in nursing or an

equivalent degree, or to a graduate degree in nursing, or is otherwise pursuing advanced professional training in nursing.

This is to certify that I am/was pursuing advanced professional training in ___________________________________________

(type of training)

at_____________________________________________________________________________

from___________________________to________________________________

__________________________________________________________________________________________________________________________________

B. For Primary Care Loan Borrowers and EFN and FADHPS Recipients:

1. Participates in a 3 year residency program in allopathic or osteopathic family medicine, internal medicine, pediatrics, combined medicine/pediatrics, or preventive medicine approved by the Accreditation Council of Graduate Medical Education (ACGME) or by the American Osteopathic Association (AOA), or in a rotating

or primary health care internship and general practice residency program approved by the AOA.

2. Participated in a residency program in General Dentistry.

This is to certify that I am/was pursuing advanced professional training in ___________________________________________

(type of residency training)

at_____________________________________________________________________________

from___________________________to________________________________.

C. Ceases to pursue the course of study at

1. A school of medicine, osteopathy, dentistry, pharmacy, podiatric medicine, optometry, or veterinary medicine, but (1) re-enters the same or

another such school within the applicable grace period (1 year); or (2) engages in a full-time educational activity as defined by regulations of the

Secretary of Health and Human Services, with the intent to return to the school as a full-time student.

2. A school of nursing leading to a diploma or an associate degree in nursing, a baccalaureate degree in nursing or an equivalent degree, or to a graduate

degree in nursing, but re-enters the same or another such school within the grace period (nine months).

This is to certify that I am/was a full-time health professions or full or half-time nursing student at __________________________________________

__________________________________________________________________________________________________________________________

from__________________________to_____________________________ pursuing a course of study leading to a ______________________(Degree).

__________________________________________________________________________________________________________________________________

D. Performs active duty as a member of a uniformed service or as a volunteer under the Peace Corps Act.

This is to certify that I was in the (enter Peace Corps or name of uniformed service) _______________________________

__________________________________________________________from__________________to_____________________.

__________________________________________________________________________________________________________________________________

E. Pursues training as a nurse anesthetist at:_____________________________________________

__________________________________________________________from__________________to_____________________.

Part III – CERTIFICATION OF DEFERMENT STATUS – To be completed by the Official Authorizing Borrower’s status.

(Note: Completion of PART III is not required for internship or residency training activity.)

Please complete this Certification of Deferment Form and return to the borrower.

A. To be completed by official of institution where borrower is/was enrolled:

I certify that the information stated in (Check appropriate space) Part II:

___A1___A2___C1___C2 (or) ___E above, is true and correct.

NAME AND ADDRESS OF SCHOOL OR HOSPITAL:	NAME AND TITLE OF AUTHORIZED OFFICIAL:
	SIGNATURE OF AUTHORIZED OFFICIAL/DATE:

B. To be completed by the Commanding Officer or Peace Corps Official.

I certify that the information stated in Part II – D, above is true and correct.

Borrower’s Uniformed Service* Serial Number:__________________

NAME AND ADDRESS OF UNIFORMED SERVICE OR PEACE CORPS OFFICIAL:	NAME AND TITLE/RANK OF COMMANDING OFFICER OR PEACE CORPS HEADQUARTERS:
	SIGNATURE OF COMMANDING OFFICER OR PEACE CORPS OFFICIAL/DATE:

PART IV – INSTITUTIONAL ACTION – To be completed by school (or its agent) from which loan was made

_______________APPROVED _________________DISAPPROVED REASONS FOR DISAPPROVAL__________________________

__________________________________________________________________________________________________________________________________

*The uniformed services of the United States are the Army, Navy, Marine Corps, Air Force, Coast Guard, National Oceanic and Atmospheric Administrations

Corps, and the U.S. Public Health Service Commissioned Corps.

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form is subject to penalties which may include fines and

Imprisonment under Federal Statute.