ࡱ>  U0bjbj ۚU(tWWWWSW\efffd=eeeeeegi`e |f  ee d d\ a@\{o*WJ(^:d,e0\eb^.jjtaa8jaf"Yfffeefff\e    jfffffffff :   Request for Deferment or Partial Cancellation Return Forms To: SOUTH DAKOTA STATE UNIVERSITY NDSL (Perkins), NSL, HPL LOAN COLLECTIONS, Box 2201 Admin 140 BROOKINGS, SD 57007 Phone: 605-688-6183, FAX: 605-688-6944 OE #: 003471 PART I -- TO BE COMPLETED BY THE BORROWER Name Loan Number Social Security No. Address (Check if new) ( ) Telephone No Home: Work: Cell: City State Zip Code Email Address Lending Institution  Signature of Borrower Date DEFERMENTS Period of Deferment From ___/___/___ To ___/___/___ (mm/dd/yy) (mm/dd/yy) ( At least halftime student in an institution of Higher Ed. ( Rehabilitation Training. ( Graduate fellowship study. ( In a nursing program ( ) Half-time ( ) Full-time leading to a ( )Baccalaureate ( )Equivalent ( )Graduate ( )Registered Nurse ( )Associate. ( Pursue a full-time course of study towards a degree in health professions at any school of medicine, osteopathy, dentistry, pharmacy, podiatry, optometry, or pursued veterinary medicine. (Circle degree pursued-HPSL only) ( Receiving full-time advanced professional training in the field for which the loan was received. (HPSL only) ( Law enforcement / Correction officer / Firefighters ( Attorneys employed in a defender organization ( Peace Corp / Action program volunteer. ( Full-time volunteer for tax-exempt organizations in service comparable to Peace Corps or Action Program. ( U.S. Armed Services (active duty). ( Officer in Commissioned Corps of the U.S. Public Health Service. ( National Oceanic & Atmospheric Adminis. Corps. ( Full-Time Nurse / Medical Tech. providing health care services. (License #_______________________) ( Employment in Head Start Programs. ( Teacher in designated low-income school. Grades taught_____ ( Teacher of Special Ed., including teacher of infants, toddlers, children or youth with disabilities. ( Teacher of mathematics, science, foreign languages, bilingual ed. or other field of expertise determined by state agency. ( Librarian ( Speech-Language Pathologist ( Pre-Kindergarten or Child Care Program ( Faculty of Tribal College or University ( Provider of early intervention services. ( Provider of services to high-risk children from low-income communities. ( Other B. EMPLOYING SCHOOL/AGENCY ( This is to certify that employment is/was full-time at the following location: ________________________________________ Name of School/Employing Agency (List exact name of school/ employing agency where employed) ________________________________________ School District and County (Required if applicable) ________________________________________ Position/ Job Title (if applicable) ________________________________________ Please include description of exact duties. C. CANCELLATION Period of Cancellation From ___/___/___ To ___/___/___ (mm/dd/yy) (mm/dd/yy) ( Law enforcement / Correction officer / Firefighters ( Attorneys employed in a defender organization ( Full-Time Nurse / Medical Tech. providing health care services. (License #_______________________) ( Head Start ( Full-time teacher of low-income school ( Teacher of the handicapped. ( Full-time special education teacher. ( Full-time teacher of mathematics, science, foreign languages, bilingual ed., or any field of expertise determined by the state agency. ( Librarian ( Speech-Language Pathologist ( Pre-Kindergarten or Child Care Program ( Faculty of Tribal College or University ( Provider of early intervention services. ( Provider of services to high risk children from low-income communities. ( I declare that I have completed one full year of active service in the Peace Corps/ Vista or Action Program. ( I declare that I have completed one full year active as a member of the Armed Forces of the United States in an area of hostilities. PART II: CERTIFICATION STATUS I certify the description of his/her duties are true and correct. The person named, Is or Was engaged in certain types of service that qualify for deferment/cancellation of their loan. Full-time employment or at least a half-time student. From ___/___/___ To ___/___/___ (mm/dd/yy) (mm/dd/yy) This space for ___________________ institutional Seal Signature of Authorized Official ___________________ Title ____________________________________ Name of School/Employing Agency OE#/County ____________________________________ Address (City, State, Zip) _______________ _________________ Phone Number Date PART III: FOR OFFICE USE ONLY AMOUNT CANCELLEDPRINCIPALINTEREST TOTAL AMT CANCELLED BALANCE DUE AFTER THIS TRANSACTION $ $  ( 1st Year 15 % ( 2nd Year 15% ( 3rd Year 20% ( 4th Year 20% ( 5th Year 30% ( Head Start 15% ( Pre-Kindergarten or Child Care 15% ( Other Cancellation ( Approved ( Disapproved Rate _________ ( Postponement ( Cancellation ( Deferment_____________ Signature ____________________________Date_________  This side is to be used for Hardship Deferment or Forbearance Request. I am requesting a temporary deferment or forbearance of the payments on my student loan. I certify that I am eligible for deferment/forbearance for the reasons listed below for the period of: From ___/___/___ To ___/___/___ (Requested period must not exceed 6 months) (mm/dd/yy) (mm/dd/yy) I understand that a deferment or forbearance may be granted for periods of 6 to 12 months (not to exceed 3 years). If my request is approved, I understand that interest may continue to accrue on some types of deferment. ________________________________________________________________ Signature of Borrower Date Complete all sections that apply and provide documentation: ( I am seeking, but unable to find full-time employment. I became unemployed or began working less then 30 hours per week on ___/___/___. (mm/dd/yy) I have registered with the following public or private employment agency. _______________________________ _________________________________ Name of Employment Agency Date Registered ______________________________________ (___)_____________________________ Address Phone number of agency _______________________________ City State Zip Enclosed are the required copies of my last two payroll or unemployment checks and certification of unemployment. ( In the last six months, I have made attempts to secure full-time employment at the following firms. Name of firm_________________ Street______________________ City______________St___Zip___ Contact Person_______________ Telephone(___)______________ Name of firm__________________ Street_______________________ City______________St___Zip____ Contact Person________________ Telephone(___)_______________ Name of firm_________________ Street______________________ City______________St___Zip___ Contact Person_______________ Telephone(___)______________ ( I am experiencing a period of Economic Hardship. Name of Present Employer__________________________________ Street___________________________________________________ City____________________________ State ________ Zip________ Number of hours worked per week: _____________ Total student loans borrowed $_________ My total monthly gross income is $_____________ Total monthly payment $_________ My adjusted gross income is $_____________ Number of Dependents $_________ ( Enclosed are copies of my monthly student loan payment notices and current payroll stubs. ( Attached is verification of approved economic hardship on another student loan. OR ( Documentation that I received payment under a federal or state public assistance program. ( I request forbearance due to extraordinary circumstances: (Check one, explain and attach documentation) ( Loans partially repaid by Student Repayment Program by completing Memorandum for Annual Loan Repayment administered by the DEPARTMENT OF DEFENSE. 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