HEAL Form 508 Borrower Deferment Request

OMB NO. 1845-0128

Exp Date: XX/XX/XXXX

BORROWER DEFERMENT REQUEST

FOR THE HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

Under Title VII, Part A, Subpart I, Public Health Service Act as amended (42 U.S.C. 292-292o) and Consolidated Appropriation Act, 2014 This form is authorized by Section 705(a)(2)(C) of the Public Health Service Act as amended.

WARNING: Any person who knowingly makes a false statement or misrepresentation in a HEAL transaction, bribes, or attempts to bribe a Federal official, fraudulently obtains a Federal HEAL loan or commits any other illegal action in connection with a Federal HEAL loan is subject to a fine or imprisonment under Federal statute.

INSTRUCTIONS

1. Provide the address of your lender.

2. Complete, sign and date Section 1.

3. Select a deferment type in Section 2.

4. For an internship, residency, fellowship or primary care deferment, complete Section 3A. For a school, Peace Corps, voluntary service, National Health Service Corps, Indian healthcare, or military deferment, have an appropriate official (listed in Section 3B) complete Section 3B.

5. Return the form to the lender/servicer listed in Section 1

SECTION 1: BORROWER SIGNATURE

NAME OF BORROWER (Type or Print)		ADDRESS (Number and Street)
SOCIAL SECURITY NUMBER		CITY	STATE	ZIP CODE

I request exemption from payment of principal and interest on my Federal HEAL loan(s). I agree to notify the lender of my deferment (or attendance) status annually, or more frequently if changes occur. I understand that installments of principal and interest need not be paid, but interest shall accrue and may, at the lender's option, be compounded according to the terms of my promissory note.

BORROWER SIGNATURE (Required for all deferment types)

Date

Borrower must provide name and address of lender/servicer.

RETURN DEFERMENT FORM TO LENDER OR SERVICER.

NAME

ADDRESS -

SECTION 2: SELECT DEFERMENT TYPE Please make sure you are eligible for the deferment type you select. CHOOSE ONE ONLY.

I wish to postpone my Federal HEAL loan payments because of:

• 1. Full time attendance at a HEAL school or a school eligible to participate in the Title IV Higher Education Act of 1965, as amended programs

• 2. Participation in an approved internship or residency (4 year limit if you received your Federal HEAL loan on or after 10/22/85 or if grace has expired)

• 3. Full time participation in an approved fellowship training program or educational activity (2 year limit)*

• 4. Full time voluntary service in the Peace Corps (3 year limit)

• 5. Full time voluntary service under the Title I Domestic Volunteer Volunteer Service Act of 1973 (VISTA/ACTION) (3 year limit)

• 6. Service as a member of the National Health Service

• 7. Full time active duty in the Armed Forces (3 year limit)

• 8. Completed approved internship or residency training in osteopathic general practice, family medicine, general internal medicine, preventive medicine, or general pediatrics

and practicing primary care (3 year limit)

• 9. Graduate of Chiropractic school (1 year limit)

• 10. Provide health care services to Indians through any health program or facility funded in whole or part by the Indian Health Service for the benefit of Indians (Section 705(a)(2)(C) of the PHS Act (3 year limit for service starting 02/01/1999 or later).

* A FELLOWSHIP TRAINING or EDUCATIONAL ACTIVITY must be directly related to the discipline for which you received your Federal HEAL loan(s), and must begin within 12 months from the time you left your accredited internship or residency program. It must NOT be part of, an extension of, or associated with your internship or residency. In addition, the FELLOWSHIP TRAINING must be a formally established fellowship program. You must participate full time in research training or health care policy, and receive either no stipend, or a stipend not greater than that for graduate and professional training under Public Health Service grants.

HEAL-508

MPORTANT: COMPLETE DEFERMENT CERTIFICATION ON FIRST PAGE

SECTION 3: DEFERMENT CERTIFICATION

1. Required for Deferment Types 2, 3 and 8 only (For deferment type 8, indicate when and where primary care residency was completed.)

PROGRAM BEGIN DATE (Month-Day-Year) / / _	PROGRAM END DATE (Month-Day-Year) / / _		PROGRAM NAME
HOSPITAL/INSTITUTION NAME		PHONE NUMBER ( )	TYPE OF RESIDENCY SPECIALTY
ADDRESS
CITY	STATE	ZIP CODE

2. Required for Deferment Types 1, 4, 5, 6, 7, 9, and 10 only.

Authorized officials for each deferment type above are: 1 and 9 - school registrar: 4 – certifying official of the Peace Corps; 5 - certifying official of the ACTION Program; 6 – certifying official for the National Health Service Corps; 7- Military Commanding Officer; or 10- certifying official of the Indian Health Service. I certify that the information stated on this form reflects the current status of the borrower or that the borrower graduated / (month/year). I also verify that I am qualified to certify this document. The borrower's deferment period begins on / / (month/day/year) and ends on / / .
SIGNATURE OF AUTHORIZED OFFICIAL			DATE		PHONE NUMBER ( )
NAME OF AUTHORIZED OFFICIAL (Please print)		TITLE		HEAL SCHOOL CODE (if applicable)
SCHOOL OR INSTITUTION NAME	ADDRESS		CITY	STATE		ZIP CODE

REMEMBER: Send this form to lender/servicer listed in Section 1.

PRA Burden Statement: 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 1845-0128. Public reporting burden for this collection of information is estimated to average 15 minutes 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 or retain benefit (Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriation Act, 2014). If you have comment or concerns regarding the status of your individual submission of this form, please contact the HEAL Program, U.S. Department of Education, 830 First Street NE, Washington, DC, 20202 directly. [Note: Please do not return the completed form to this address.].

PRIVACY ACT NOTIFICATION STATEMENT

The Privacy Act of 1974 (5 U.S.C. 552a) requires that an agency provide the following notification to each individual whom it asks to supply information. The following information is contained in the system of records 18-11-20 entitled "Health Education Assistance Loan Program."

1. The authority for collecting the requested information is found in Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 292-292o) and the Consolidated Appropriations Act, 2014.

2. The principal purposes of this information are as follows: to verify the identity of the applicant; to determine program eligibility and benefits; to permit servicing of the loan; and in the event it is necessary, to locate missing borrowers and collect on delinquent or de­faulted loans.

3. The routine uses include the following: the information may be furnished during the life of the loan to holders of this and other loans made to the borrower under the HEAL Program; to educational institutions in which the borrower is enrolled or is accepted for enrollment; to guarantee agencies; to contractors which assist the Department of Education in the administration of the HEAL Program; to Federal or State agencies or private parties who may be able to provide information necessary for the collection of the loan or to assist in the servicing or collection of the loan. Disclosures may also be made to consumer reporting agencies in order to aid in the collection of outstanding debts owed to the Federal Government. Disclosure of records will consist of the individual's name, social security number, and other information necessary to establish the identity of the individual, the amount, status, and history of the claim, and the agency or program under which the claim arose.

Section 3(c) of the Privacy Act (5 U.S.C. 552a) requires that an agency keep an accounting of disclosures of individually identified information from a system of records to all third parties outside of the Department of Education. Upon an individual's written request to the System Manager, an agency must make the accounting of such dis­closures available to the subject individual.

Section 7(b) of the Privacy Act of 1974 (5 U.S.C. 552a) requires that where any Federal, State, or local government agency requests an individual to disclose his or her social security account number (SSN), that the individual must also be advised whether that disclosure is mandatory or voluntary, by what statutory or other authority the SSN is solicited, and what uses will be made of it.

Disclosure of the applicant's SSN is mandatory for participation in the HEAL Program as provided for by Section 4 of the Debt Collection Act of 1982 (26 U.S.C. 6103 note). Applicants are advised that failure to provide his/her SSN will result in the denial of the individual to participate in the HEAL Program. The SSN will be used to verify the identity of the applicant and as an account number (identifier) throughout the life of the loan to record necessary data accurately. As an identifier, the SSN is used in such program activities as: determining program eligibility; certifying school attendance and student status; determining eligibility for deferment of repayment; determining eligibility for disability or death claims, and for tracing and collecting in cases of delinquent or defaulted loans.

FINANCIAL PRIVACY ACT

Under the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401-3412), the Department of Education will have access to financial records in your student loan file maintained by the Lender in connection with the administration of the HEAL Program.

HEAL-508 Page 2