CANCER
TREATMENT DEFERMENT REQUEST |
OMB
No. 1845-0011 |
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.
You never need to pay for help with your federal student loans. Your loan servicer will help you for FREE. Contact your servicer if you have questions about this form or need any information regarding your federal student loans.
SECTION 1: BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
Social Security Number (SSN) _________________________________________
Date of Birth (mm-dd-yyyy) _________________________________________
Name __________________________________________________________________
Address __________________________________________________________________
City _________________________________________
State ____________
Zip Code ____________
Phone – Primary ___________________________________
Phone – Alternate ___________________________________
Email ___________________________________
SECTION 2: BORROWER DETERMINATION OF DEFERMENT ELIGIBILITY
To qualify, you must be (or must have been) receiving treatment for cancer (as certified by a physician in Section 4) and have a loan under the Direct Loan Program, FFEL Program, or Perkins Loan Program which either was made on or after September 28, 2018 or had entered repayment on or before September 28, 2018.
SECTION 3: BORROWER REQUESTS, UNDERSTANDINGS, AND AUTHORIZATION
I request:
A deferment on my eligible loans and forbearance on my ineligible loans during cancer treatment and for 6 months after.
I want to make interest payments on my ineligible loans during forbearance.
I do not want a forbearance to be applied to my loans which are ineligible for the deferment.
I understand that:
I am not required to make payments of loan principal or interest during my deferment or forbearance.
My deferment or forbearance will begin on the later of September 28, 2018, or when I began receiving treatment.
My loan holder may grant me a forbearance while processing my application or to cover any period of delinquency.
If my treatment is expected to last for longer than 1 year, my loan holder may assume that my treatment will last one year, but give me the opportunity to extend my deferment based on another certification from my physician.
I am not responsible for paying interest on my loans that receive an interest subsidy during the deferment.
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 Signature ___________________________________________________________
Date (mm-dd-yyyy)____________________________________________
SECTION 4: PHYSICIAN CERTIFICATION
Note: As an alternative to having your physician complete this section, you may attach separate documentation from a doctor of medicine or osteopathy legally authorized to practice medicine that includes all of the information requested below.
Is or was the individual identified in Section 1 scheduled to receive or receiving cancer treatment in your care?
Yes.
No.
Has the treatment been completed yet?
Yes.
No.
When will or when did the treatment begin? (mm-dd-yyyy)_________________________________
When did or when is the treatment expected to end? (mm-dd-yyyy)_________________________________
I certify, to the best of my knowledge and belief, and in my best medical judgment: that the information that I have provided is accurate and that I am a doctor of medicine or osteopathy who is legally authorized to practice medicine.
Physician's Name _______________________________________________________
Phone _____________________________________
Address _______________________________________________________
City _____________________________________
State ___________________
Zip Code ___________________
Physician's Signature ______________________________________________________
Date (mm-dd-yyyy)____________________
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, 2024 = 03-14-2024. Include your name and account number on any documentation that you are required to 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. If you have loans that were made jointly to you and your spouse (as co-makers), both of you must individually meet the requirements for a deferment and each of you must submit a separate deferment request. Return the completed form and any required documentation to the address shown in Section 7.
SECTION 6: DEFINTIONS
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.
The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans, Federal PLUS Loans, Federal Consolidation Loans, and Federal Supplemental Loans for Students (SLS).
The Federal Perkins Loan (Perkins Loan) Program includes Federal Perkins Loans, National Direct Student Loans (NDSL), and National Defense Student Loans (Defense Loans).
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. Interest never capitalizes on Perkins Loans. The capitalization chart below provides an example of the monthly payments and the total amount repaid for a $30,000 FFEL Program loan not held by the Department. The example loan has a 6% interest rate and the example 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 co-maker is one of the two individuals who are joint borrowers on a Direct or Federal Consolidation Loan or a Federal PLUS Loan. Both co-makers are equally responsible for repaying the full amount of the loan.
A deferment is a period during which you are entitled to postpone repayment of your eligible loans. For deferment types other than the cancer treatment deferment, interest is not charged during the deferment period on subsidized loans, but interest is charged on unsubsidized loans. However, for the cancer treatment deferment, no interest is charged during the deferment period on any of the following subsidized and unsubsidized loan types:
Direct Subsidized Loans
Direct Unsubsidized Loans
Direct PLUS Loans made to students
Direct PLUS Loans made to parents
Direct Subsidized Consolidation Loans
Direct Unsubsidized Consolidation Loans
Direct PLUS Consolidation Loans
Federal Perkins Loans
Federal Subsidized Stafford Loans
Federal Unsubsidized Stafford Loans
Federal Subsidized Consolidation Loans
Interest is charged during periods of cancer treatment deferment on the following loan types:
Federal PLUS Loans
Federal Unsubsidized Consolidation Loans
Federal Supplemental Loans for Students (SLS)
National Direct Student Loans (NDSL)
National Defense Student Loans (Defense Loans)
For any loan type on which interest is charged during a period of cancer treatment deferment, unpaid interest that accrues during the deferment period is capitalized at the end of the deferment on loans that are held by the Department. For these loan types that are not held by the Department, unpaid interest that accrues during the deferment period is capitalized at the end of the deferment but may be capitalized as frequently as quarterly on loans disbursed prior to 7/1/2000.
On loans made under the Perkins Loan Program, all deferments are followed by a post-deferment grace period of 6 months, during which time you are not required to make payments.
An eligible loan for the purposes of the Cancer Treatment Deferment is a loan under the Direct Loan Program, FFEL Program, or Perkins Loan Program which either was made on or after September 28, 2018 or had entered repayment on or before September 28, 2018.
A forbearance is a period during which you are permitted to postpone making payments temporarily, allowed an extension of time for making payments, or temporarily allowed to make smaller payments than scheduled. Interest is charged during a forbearance on both subsidized and unsubsidized loans. Unpaid interest that accrues during a forbearance on a Direct Loan or on a FFEL Program loan that is held by the Department is not capitalized. Unpaid interest that accrues during a forbearance on a FFEL Program loan that is not held by the Department may be capitalized at the end of the forbearance but may be capitalized as frequently as quarterly on loans disbursed prior to 7/1/2000.
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. The holder of your Perkins Loans is an institution of higher education 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, portions of some Federal Consolidation Loans, a Federal Perkins Loan, an NDSL, and a Defense Loan.
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.
Capitalization Chart (Note: this chart only applies to FFEL Program loans that are not held by the Department)
Treatment of Interest with Forbearance |
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 |
SECTION 7: WHERE TO SEND THE COMPLETED APPLICATION
Return
the completed form and any documentation to:
(If no address is
shown, return to your loan holder.)
|
SECTION 8: HELP WITH COMPLETING THE APPLICATION
If
you need help completing this form, call:
(If no phone number
is shown, call your loan holder.)
|
SECTION 9: IMPORTANT NOTICES
Privacy Act Statement.
Authority: 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 William D. Ford Federal Direct Loan (Direct Loan) Program or Federal Family Education Loan (FFEL) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate.
Purpose: The principal purposes for collecting the information on the Cancer Treatment Deferment Request 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, to enforce the conditions or terms of a title IV, HEA obligation, to originate, disburse, service, collect, assign, adjust, transfer, refer, furnish credit information for, and discharge a title IV, HEA obligation, to verify whether a title IV, HEA obligation qualifies for discharge, to determine credit balances to be refunded by the U.S. Department of the Treasury (Treasury) to the individual or loan holder, and, if it becomes necessary, to locate you and to collect and report on your loans if your loans become delinquent or default. We also use your SSN as an account identifier and to permit you to access your account information electronically.
Disclosures: The information provided on the Cancer Treatment Deferment Request form will only be disclosed outside of the U.S. Department of Education (Department) with prior written consent or as otherwise allowed by the Privacy Act of 1974, as amended (Privacy Act) (5 U.S.C. 552a). One of the exceptions to the Privacy Act’s prior written consent requirement that allows for disclosure, without consent, is for “routine uses” that the Department publishes in our System of Records Notices (SORNs). The Department may disclose, without consent, the information provided on a Cancer Treatment Deferment Request form, on a case-by-case basis or under a computer matching program, to third parties pursuant to the routine uses identified in the “Common Services for Borrowers (CSB) System” (18-11-16) SORN. This notice is available on the Department’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.
These routine uses include, but are not limited to, the following:
To verify the identity of the individual who records indicate has applied for or received title IV, HEA program funds, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, Tribal, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; to adjudicative bodies; and to the individual whom the records identify as the party obligated to repay the title IV, HEA obligation;
To determine program eligibility and benefits, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; and to adjudicative bodies;
To provide customers with information to help them make informed decisions on repayment options, including deferment, forbearance, and recurring auto debit, based on their unique situations, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; and to Federal, State, or local agencies, and their authorized representatives.
For additional routine uses, view the “Common Services for Borrowers (CSB) System” (18-11-16) SORN. This notice is available on the Department’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.
Consequences of Failure to Provide Information: Participating in the Federal Family Education Loan (FFEL) Program or the William D. Ford Federal Direct Loan (Direct Loan) Program and providing the Department your SSN and requested information is mandatory to participate.
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 HEA 455(f)(3) (20 U.S.C. 1087e(f)(3)).
If you have comments or concerns regarding the status of your individual submission of this form, contact your loan holder directly.
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04/24/2024
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jon Utz |
| File Modified | 0000-00-00 |
| File Created | 2024-09-24 |