Perkins Assignment Form_2021 rev

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

OMB Number: 1845-0048
Form in Review
Expiration Date:

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)
8. City

9. State or Province

7. Telephone Number
10. Zip Code

Foreign Add?

10.a Country

United States

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

SECTION C - LOAN INFORMATION: HISTORICAL
18. Type of Loan (Check appropriate space)
19. Applicable Interest Rate on the Loan
Perkins

Direct

Defense

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

20. Date of First Disbursement

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

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

24. 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)

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

NO

Date (MM/DD/YYYY)

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

Grace Period

Deferment

Repayment

27. 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
28. Disbursement Amount

29. Principal Amount Adjusted

30. Principal Amount Repaid

31. Principal Amount Cancelled

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

33. Collections Costs Repaid

34. Interest Repaid

35. Interest Cancelled

36. Interest Due

37. Collection Costs/Penalty/Late Charges

38. Total Amount Outstanding (Sum of Items 32, 36, and 37)

SECTION E - CANCELLATION INFORMATION (See Instructions)
Cancellation(s) Granted for this Loan

39.
Type of Cancellation

40.
Percentage
Rate

41.
Principal
Cancelled

42.
Interest
Cancelled

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

44.
Cancellation Service
End Date
(MM/DD/YYYY)