Direct Loan Program Internship/Residency Forbearance Req

OMB No. 1845-0018 Form Approved Exp. Date xx/xx/xxxx IRFB Internship/Residency

INTERNSHIP/RESIDENCY FORBEARANCE REQUEST William D. Ford Federal Direct Loan Program WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents will be subject to penalties which may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: BORROWER IDENTIFICATION PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK

Please correct or, if information is missing, enter below. SSN |__|__|__|-|__|__|-|__|__|__|__|

Name

Address

City, State, Zip

Telephone - Home ( )

Telephone - Other ( )

E-mail Address (optional)

SECTION 2: FORBEARANCE REQUEST

Before completing this form, carefully read the entire form, including the instructions and other information in Sections 5, 6, and 7. YOU MUST HAVE AN AUTHORIZED OFFICIAL COMPLETE SECTION 4.  If this forbearance request is approved, I want to (check one): temporarily stop making payments; or make smaller payments of $__________ per month.  I meet the required conditions stated in Section 7 for the forbearance checked below and request that the U.S. Department of Education (ED) grant a forbearance on my loan(s) beginning (MM-DD-YYYY) |__|__|-|__|__|-|__|__|__|__| and ending (MM-DD-YYYY) |__|__|-|__|__|-|__|__|__|__| for a period not to exceed 12 months. At the end of the forbearance, I may apply to renew the forbearance if I meet the required conditions.  I am engaged in a MEDICAL OR DENTAL INTERNSHIP/RESIDENCY program that (check one): must be successfully completed before I may begin professional practice or service (state licensing agency certification required); or leads to a degree or certificate awarded by an institution of higher education, a hospital, or a health care facility that offers postgraduate training.

SECTION 3: BORROWER UNDERSTANDINGS AND CERTIFICATIONS

 I understand that the following terms and conditions apply to this forbearance request: (1) I will continue to receive billing statements for my current payment amount which I must pay until I am notified by the Direct Loan Servicing Center that my forbearance request has been granted. (2) ED may grant me a forbearance on my loans for up to 60 days, if necessary, for the collection and processing of documentation related to my forbearance request. ED will not capitalize interest that accrues during this forbearance. (3) ED will not grant this forbearance request unless this form is completed and any required documentation is provided. (4) During the forbearance period, I am not required to make payments of loan principal and interest, but interest will be charged on all of my loans. (5) If I requested a temporary suspension of payments, I will receive an interest statement, and I may pay the interest at any time. If I do not pay the interest that accrues on my loan(s), it will be capitalized at the end of the forbearance period. (6) If I requested a reduced payment forbearance, I will receive a monthly bill for the requested payment amount until the forbearance ends, and any unpaid interest that has accrued during the period will be capitalized at the end of the forbearance period.  I certify that: (1) The information I have provided on this form is true and correct. (2) I will provide additional documentation to the Direct Loan Servicing Center, as required, to support my continued forbearance status. (3) I will notify the Direct Loan Servicing Center immediately when the condition that qualified me for the forbearance ends. (4) I have read, understand, and meet the eligibility requirements of the forbearance for which I have applied. (5) Upon termination of this forbearance, I will repay my loan(s) according to the terms of my promissory note and repayment schedule.

BORROWER’S SIGNATURE

DATE

SECTION 4: AUTHORIZED OFFICIAL’S CERTIFICATION

I certify, to the best of my knowledge and belief, that: (1) the borrower named above is/was a student engaged in the medical or dental internship/residency program indicated in Section 2 from (MM-DD-YYYY) |__|__|-|__|__|-|__|__|__|__| to (MM-DD-YYYY) |__|__|-|__|__|-|__|__|__|__| and (2) the borrower and the borrower's program meet all the eligibility requirements in Section 7.

Institution's Name

ID #

Address

City, State, Zip

Name/Title of Authorized Official

Telephone ( )

AUTHORIZED OFFICIAL’S SIGNATURE

DATE

SECTION 5: INSTRUCTIONS FOR COMPLETING THE INTERNSHIP/RESIDENCY FORBEARANCE REQUEST FORM
Type or print using dark ink. Report dates as month-day-year. For example, show “January 31, 2007” as “01-31-2007”. REMEMBER TO SIGN AND DATE THE FORM AND HAVE AN AUTHORIZED OFFICIAL COMPLETE SECTION 4.
Send the completed form and any required documentation to: U.S. Department of Education Direct Loan Servicing Center P.O. Box 5609 Greenville, TX 75403-5609	If you need help completing this form, call: 1-800-848-0979 If you use a telecommunications device for the deaf (TDD), call: 1-800-848-0983 Direct Loan Servicing Center web site: www.dl.ed.gov
SECTION 6: DEFINITIONS
 An authorized official who may complete Section 4 is an authorized official of the medical or dental internship/residency program, or, for all internships required to begin professional practice or service, a state licensing official.  If unpaid interest is capitalized, this means that it is added to the principal balance of your loan(s). This will increase the principal amount and the total cost of your loan(s).  A forbearance allows you to temporarily postpone making payments on your loan(s) or lets you temporarily make smaller payments than previously scheduled. Interest is charged during a forbearance on all types of Direct Loans.  The William D. Ford Federal Direct Loan (Direct Loan) Program includes Federal Direct Stafford/Ford (Direct Subsidized) Loans, Federal Direct Unsubsidized Stafford/Ford (Direct Unsubsidized) Loans, Federal Direct PLUS (Direct PLUS) Loans, and Federal Direct Consolidation (Direct Consolidation) Loans. These loans are known collectively as “Direct Loans”.
SECTION 7: ELIGIBILITY REQUIREMENTS
 You must have been accepted into a medical or dental internship/residency program that is a supervised training program and that requires you to hold a Bachelor's Degree before acceptance into the program.  Your medical or dental internship/residency program must either: be required before you may be certified for professional practice or service; or lead to a degree or certification from an institution of higher education, a hospital, or a health care facility that offers postgraduate training.  If your medical or dental internship/residency program is required before you may be certified for professional practice or service, you must attach to this form a separate statement from your state licensing agency which certifies that your internship/residency, in whole or in part, is required before you may be certified for professional practice or service.
SECTION 8: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authority for collecting the requested information from and about you is §451 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the William D. Ford Federal Direct Loan (Direct Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate. The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the Direct Loan Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. We also use your SSN as an account identifier and to permit you to access your account information electronically. The information in your file may be disclosed, on a case-by-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions to efficiently submit student enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies. In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0011. The time required to complete this information collection is estimated to average 0.16 hours (10 minutes) per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4537. Do not send the completed form to this address. If you have questions about the status of your individual submission of this form, contact the Direct Loan Servicing Center (see Section 5).

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