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D
OMB
No. 1845-0080 Form
Approved Exp.
Date XX/XX/XXXX
30-DAY
CLEARANCE DRAFT 04/26/2010
Federal Family Education Loan Program / William D. Ford Federal Direct Loan Program / Federal Perkins Loan Program WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents is subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097. |
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SECTION 1: BORROWER IDENTIFICATION |
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Please enter or correct the following information. |
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SSN |
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Name |
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Address |
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City, State, Zip Code |
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Telephone – Home ( ) |
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Telephone – Other ( ) |
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E-mail Address (Optional) |
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SECTION 2: ELIGIBILITY REQUIREMENTS AND DEFERMENT REQUEST |
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Before completing this deferment request, carefully read the entire form For the military service deferment, a representative may complete and sign this form on your behalf if you are unable to do so. Check the appropriate box(es) for the deferment(s) you are requesting. For the Post-Active Duty Student Deferment, enter the required information in the space provided. (A) Military Service Deferment. I meet the eligibility requirements for this deferment as described in Sections 6 and 7 and request that my loan holder defer repayment of my eligible loan(s) beginning on the date I began performing the military service that qualifies me for the deferment, and ending 180 days after the ending date of each period of qualifying service. If I am requesting a deferment for military service that ended before October 1, 2007, the deferment period will end on the ending date of my qualifying military service. |
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(B) Post-Active Duty Student Deferment. I meet the eligibility requirements for this deferment as described in Sections 6 and 7 and request that my loan holder defer repayment of my eligible loans following the completion of my qualifying active duty service and any applicable grace period. My deferment will end the earlier of (a) the date I resume enrollment at an eligible school on at least a half-time basis, or (b) 13 months following the completion date of my active duty service and any applicable grace period. If I am also granted a Military Service Deferment, the 180-day period described in Item A above will run at the same time as my Post-Active Duty Student Deferment period. Enter the name of the school where you were enrolled on at least a half-time basis at the time you were called to active duty or within 6 months before the date you were called to active duty, and the date you were last enrolled at least half time at the school: Name of school: _______________________________________________________________________________ Date last enrolled at least half time: ______________________________ |
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SECTION 3: BORROWER CERTIFICATIONS AND AUTHORIZATION |
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I certify that the information I have provided on this form is true and correct, and that I have read, understand, and meet the eligibility requirements and terms and conditions of the deferment(s) that I have requested, as explained in Sections 2, 6, and 7. I authorize my school, lender, guaranty agency, the U.S. Department of Education, and their respective agents and contractors to contact me regarding my loan request or my loan, including repayment of my loan(s), at the current or any future number that I provide for my cellular telephone or other wireless device using automated telephone dialing equipment or artificial or prerecorded voice or text messages. |
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Signature of Borrower or Borrower’s Representative |
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Date |
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Printed Name of Borrower’s Representative (if applicable) |
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Relationship to Borrower |
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Address of Borrower’s Representative |
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Telephone ( ) |
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SECTION 4: AUTHORIZED OFFICIAL’S CERTIFICATION |
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Note: As an alternative to completing this section, a written statement from the commanding or personnel officer or a copy of the military orders may be attached. The statement or copy must include all information needed to establish the borrower’s eligibility for the deferment(s) indicated in Section 2, including the period of the qualifying service, and if the borrower is/was serving in an area of hostilities in which service qualifies for special pay under section 310 of title 37, United States Code, the hostile fire/imminent danger pay area in which the borrower is/was on active duty. I certify, to the best of my knowledge and belief, that: The borrower’s service meets the eligibility requirements for the deferment(s) indicated in Section 2, as described in Sections 6 and 7, as applicable. The borrower’s service begins/began on |__|__|-|__|__|-|__|__|__|__| (mm-dd-yyyy) and ends/ended on |__|__|-|__|__|-|__|__|__|__| (mm-dd-yyyy). If the borrower is requesting a Military Service Deferment (see Section 2, Item A) -- (1) The borrower is (check one): A member of an Armed Force reassigned to a duty station at a location other than the location where the member is normally assigned. A Reserve or Retired member of an Armed Force called to Active Duty under 10 U.S.C. 12301(a), 12301(g), 12302, 12304, 12306, or 688. On full-time National Guard duty as defined in 10 U.S.C. 101(d)(5) under a call to active duty service authorized by the President or the Secretary of Defense. Note: If none of the above conditions apply, do not complete this form. (2) The reassignment/call to Active Duty/full-time National Guard duty is in connection with (check one and identify): Operation Enduring Freedom Operation Iraqi Freedom Other Contingency Operation (identify): ___________________________________________________________________________________________________________________ A National Emergency (identify): ________________________________________________________________________________________________________________ A War (identify): ____________________________________________________________________________________________________________________________ Note: If the borrower’s service is not in connection with a contingency operation, national emergency, or war, do not complete this form. (3) If applicable, by checking this box I further certify that the borrower is/was serving in an area of hostilities in which service qualifies for special pay under section 310 of title 37, United States Code. |
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Name of Military Branch or National Guard Component |
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Address |
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City, State, Zip Code |
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Name/Title of Authorized Official |
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Telephone ( ) |
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Authorized Official’s Signature |
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Date |
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SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM |
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SECTION 6: DEFINITIONS |
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*Total amount repaid includes $1,350 of interest paid during the 12-month period of deferment.
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SECTION 7: ELIGIBILITY REQUIREMENTS AND TERMS/CONDITIONS FOR MILITARY SERVICE DEFERMENT OR POST-ACTIVE DUTY STUDENT DEFERMENT |
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SECTION 8: WHERE TO SEND THE COMPLETED DEFERMENT REQUEST |
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Return the completed deferment request and any required documentation to: (If no address is shown, return to your loan holder.)
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If you need help completing this form, call: (If no telephone number is shown, call your loan holder.) |
SECTION 9. IMPORTANT NOTICES |
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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 §421 et seq., §451 et seq., and/or §461 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., and/or 20 U.S.C. 1087aa 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 Federal Family Education Loan (FFEL) Program, William D. Ford Federal Direct Loan (Direct Loan) Program, and Federal Perkins Loan (Perkins) 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 FFEL Program, Direct Loan Program, and/or Perkins 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 1845-0080. The time required to complete this information collection is estimated to average 0.5 hours (30 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 any 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
If you have questions regarding the status of your individual submission of this form, contact your loan holder (see Section 8). |
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File Type | application/msword |
File Title | CLO.FFEL-DL-P.rev8 |
Author | EPJUTZ |
Last Modified By | Jon Utz |
File Modified | 2010-04-26 |
File Created | 2010-04-26 |