Perkins Assignment Form

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Federal Perkins Loan Program/NDSL
Assignment Form: Borrower and Loan Information

OMB Number: 1845-0048
Form Approved
Expiration Date: XXXXX

SECTION A - BORROWER INFORMATION
2. Previous Name(s) (Optional)

1. Current or Last Known Name (Last, First, MI)
3. Social Security Number

4. Date of Birth (MM/DD/YYYY)

5. Departure Date (MM/DD/YYYY)

6. Current or Last Known Permanent Address (Number and Street)

7. Telephone Number

9. State

8. City

10. Zip Code

State
SECTION B - COSIGNER INFORMATION (Complete if applicable)
11. Name of Cosigner of Loan (Last, First, MI)

12. Social Security Number of Cosigner
(optional)

13. Current or Last Known Permanent Address of Cosigner (Number and Street)

14. Telephone Number

15. City

17. Zip Code

16. State

State
SECTION C - LOAN INFORMATION: HISTORICAL
18. Type of Loan (Check appropriate space)
Perkins

Direct

19. Applicable Interest Rate on the Loan
%

Defense

20. Date of Last Disbursement (MM/DD/YYYY)

21. Date Last Grace Period Ended or Will End
(MM/DD/YYYY)

22. Date of Default, if defaulted (MM/DD/YYYY)

23. Was this loan ACCELERATED? (Check appropriate space)
If YES, provide date of acceleration. If NO, provide date this loan became fully mature (due-in-full). In the case of a non-defaulted loan that
has neither been accelerated nor matured (such as a total and permanent disability discharge or if the schools closing out the program), check
“No” and leave the date blank.
YES

NO

Date (MM/DD/YYYY)

24. Was this loan LITIGATED? (Check appropriate space) If YES, provide effective date and attach judgement.
YES

NO

Date (MM/DD/YYYY)

25. Borrower Repayment Status, if loan is not in default.
In School

Grace Period

Deferment

Repayment

26. Reason this loan is being assigned or has been determined uncollectible. (Check appropriate space)
Hardship
Refusal to Pay

Incarceration
Address Unknown

Unemployment

Liquidation

Total and Permanent Disability

Other (Please Explain Below)

SECTION D - LOAN INFORMATION: FINANCIAL
27. Disbursement Amount

28. Principal Amount Adjusted

29. Principal Amount Repaid

30. Principal Amount Cancelled

31. Principal Amount Outstanding
(27 less 28, 29, & 30)

32. Collections Costs Repaid

33. Interest Repaid

34. Interest Cancelled

35. Interest Due

36. Collection Costs/Penalty/Late Charges

37. Total Amount Outstanding (Sum of Items 31, 35, and 36)

SECTION E - CANCELLATION INFORMATION (See Instructions)
Cancellation(s) Granted for this Loan
38.
Type of Cancellation

39.
Percentage
Rate

40.
Principal
Cancelled

41.
Interest
Cancelled

42.
Cancellation Service
Start Date
(MM/DD/YYYY)

43.
Cancellation Service
End Date
(MM/DD/YYYY)