Temporary Total Disability Deferement Request

TDIS

TEMPORARY TOTAL DISABILITY DEFERMENT REQUEST

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family Education Loan (FFEL) Program

OMB No. 1845-0011

DRAFT FORM

Exp. Date XX/XX/XXXX

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document is subject to penalties that may include fines, imprisonment, or both, under the U. S. Criminal Code and 20 U. S. C. 1097.

SECTION 1: BORROWER IDENTIFICATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN

Name

Address

City, State, Zip Code

Telephone – Primary

Telephone – Alternate

E-mail (Optional)

___ ___ ___ - ___ ___ - ___ ___ ___ ___

___________________________________________

___________________________________________

________________________ , _______ __________

( ___________ ) ___________ - _________________

( ___________ ) ___________ - _________________

___________________________________________

SECTION 2: BORROWER DETERMINATION OF DEFERMENT ELIGIBILITY

Carefully read the entire form before completing it. Maximum eligibility for this deferment is 36 months. To qualify, you must have an outstanding balance on a FFEL Program loan that was first disbursed before July 1, 1993 or had a balance on a FFEL Program loan first disbursed before July 1, 1993 when you obtained a loan on or after July 1, 1993.

1. Are you temporarily totally disabled?

Yes – Continue to Item 2.

No – Skip to Item 6.

2. Are you unable to work and earn money or go to school for at least 60 days to recover from an injury or illness?

Yes – Continue to Item 3.

No – You are not eligible for this deferment.

3. Are you applying for this deferment due to an illness or injury that existed before you applied for your loans? For consolidation loans, answer based on your health when you received the loans you consolidated.

Yes – Continue to Item 4.

No – Skip to Item 5.

4. Has that illness or injury substantially deteriorated since you received your loans?

Yes – Continue to Item 5.

No – You are not eligible for this deferment.

5. Are you requesting this deferment based on an uncomplicated pregnancy?

Yes – You are not eligible for this deferment.

No – Continue to Section 3 and have a physician complete Section 4.

6. Are you caring for a spouse or dependent who is temporarily totally disabled?

Yes – Continue to Item 7.

No – You are not eligible for this deferment.

7. Does your spouse or dependent have an injury or illness that requires at least 90 days of continuous nursing or similar care from you?

Yes – Continue to Item 8.

No – You are not eligible for this deferment.

8. Does the care you are providing prevent you from securing full-time employment (see Section 6)?

Yes – Continue to Item 9.

No – You are not eligible for this deferment.

9. Are you requesting this deferment based on your spouse’s or dependent’s uncomplicated pregnancy?

Yes – You are not eligible for this deferment.

No – Complete Section 3 and have a physician complete Section 4.

Borrower Name: ______________________________ Borrower SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 3: BORROWER REQUESTS, UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION

I request:

• To defer repayment of my loans for the period during which I meet the eligibility criteria outlined in Section 2. If I am requesting this deferment based on caring for my spouse or dependent, their information is as follows:

Name of Spouse/Dependent ________________________ Relationship to me: _____________________

• If indicated below, to pay the interest that accrues on my unsubsidized loans during the deferment.

I wish to make interest payments on my loans during my deferment.

I understand that:

• I am not required to make payments of loan principal or interest during my deferment.

• My deferment will begin, as certified by the physician, on the date I became eligible for the deferment.

• My deferment will end on the earlier of the date I exhaust my maximum eligibility for the deferment, 6 months from the date my deferment begins, or the date, certified by the physician, I no longer qualify for the deferment.

• Interest may capitalize or some or all of my loans during or at the expiration of my deferment or forbearance.

I certify that:

• The information I have provided on this form is true and correct.

• I will provide additional documentation to my loan holder, as required, to support my deferment eligibility.

• I will notify my loan holder immediately when my eligibility for the deferment ends.

• I have read, understand, and meet the eligibility criteria in Section 2.

I authorize the entity to which I submit this request and its agents to contact me regarding my request or my loans at any cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or prerecorded voice or text messages.

Borrower’s/Representative’s Signature: ______________________________ Date: ___ ___ - ___ ___ - ___ ___ ___ ___

Rep. Name (if applicable): __________________________

Rep. Address: ____________________________________

Relationship to Borrower: __________________________

Rep. Telephone: ( ________ ) ________ - _____________

SECTION 4: PHYSICIAN’S CERTIFICATION

Note: As an alternative to completing this section, you may attach separate documentation from a doctor of medicine or osteopathy legally authorized to practice that includes all of the information requested below.

• Check one:

The borrower is unable to work and earn money or attend school for at least 60 days because of a medically determinable impairment.

The individual identified in Section 3 requires continuous nursing or similar care for a period of at least 90 days.

• When did the disabling condition or care begin?

___ ___ - ___ ___ - ___ ___ ___ ___

• When is the disabling condition or care expected to end?

___ ___ - ___ ___ - ___ ___ ___ ___

• What is the disabled person’s current diagnosis?

____________________________________________

I certify, to the best of my knowledge and belief and in my best medical judgment, that: (1) that the information that I have provided this section about the disabled individual is accurate and (2) I am a doctor of medicine or osteopathy who is legally authorized to practice.

Physician’s Name:_________________________________

Address:________________________________________

Physician’s Signature:_____________________________

Telephone: ( ________ ) ________ - ______________

City, State, Zip Code:______________ , ____ _______

Date: ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 5: INSTRUCTIONS FOR COMPLETING THE DEFERMENT REQUEST

Type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Example: March 14, 2015 = 03-14-2015. Include your name and account number on any documentation that you submit with this form. If you want to apply for a deferment on loans that are held by different loan holders, you must submit a separate deferment request to each loan holder. Return the completed form and any required documentation to the address shown in Section 7.

SECTION 6: DEFINITIONS

Capitalization is the addition of unpaid interest to the principal balance of your loan. Capitalization causes more interest to accrue over the life of your loan and may cause your monthly payment amount to increase. Table 1 (below) provides an example of the monthly payments and the total amount repaid for a $30,000 unsubsidized loan. The example loan has a 6% interest rate and the example deferment or forbearance lasts for 12 months and begins when the loan entered repayment. The example compares the effects of paying the interest as it accrues or allowing it to capitalize.

A deferment is a period during which you are entitled to postpone repayment of your loans. Interest is not generally charged to you during a deferment on your subsidized loans. Interest is always charged to you during a deferment on your unsubsidized loans.

The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans, Federal PLUS Loans, Federal Consolidation Loans, and Federal Supplemental Loans for Students (SLS).

Full-time employment is defined as working at least 30 hours per week in a position expected to last at least 3 consecutive months.

The holder of your Direct Loans is the Department. The holder of your FFEL Program loans may be a lender, guaranty agency, secondary market, or the Department. Your loan holder may use a servicer to handle billing and other communications related to your loans. References to “your loan holder” on this form mean either your loan holder or your servicer.

A subsidized loan is a Direct Subsidized Loan, a Direct Subsidized Consolidation Loan, a Federal Subsidized Stafford Loan, and portions of some Federal Consolidation Loans.

An unsubsidized loan is a Direct Unsubsidized Loan, a Direct Unsubsidized Consolidation Loan, a Direct PLUS Loan, a Federal Unsubsidized Stafford Loan, a Federal PLUS Loan, a Federal SLS, and portions of some Federal Consolidation 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.

Table 1. Capitalization Chart

Treatment of Interest	Loan Amt.	Capitalized Interest	Outstanding Principal	Monthly Payment	Number of Payments	Total Repaid
Interest is paid	$30,000	$0	$30,000	$333	120	$41,767
Interest is capitalized at the end	$30,000	$1,800	$31,800	$353	120	$42,365
Interest is capitalized quarterly and at the end	$30,000	$1,841	$31,841	$354	120	$42,420

SECTION 7: WHERE TO SEND THE COMPLETED DEFERMENT REQUEST

Return the completed form and any required documentation to:

If you need help completing this form, call:

(If no phone number is shown, call your loan holder.)

(If no address is shown, return to your loan holder.)

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 authorities for collecting the requested information from and about you are §421 et seq. and §451 et seq. of the Higher Education Act of 1965, as amended (20 U.S.C. 1071 et seq. and 20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Education Loan (FFEL) Program or 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 FFEL and/or Direct Loan Programs, to permit the servicing of your loans, and, if it becomes necessary, to locate you and to collect and report on your loans if your loans becomes delinquent or defaults. 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 loans, to enforce the terms of the loans, 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 statuses, 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.

SECTION 8: IMPORTANT NOTICES (CONTINUED)

Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0011. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain a benefit in accordance with 34 CFR 682.210 or 685.204. If you have comments or concerns regarding the status of your individual submission of this form, please contact your loan holder directly (see Section 7).

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