Form 1 Revolving Loans Deferment Form

OMB No.: 0 915-0047

Student Loan Deferment Request

Health Professions Student Loan (HPSL)

Loans for Disadvantaged Students (LDS)

Nursing Student Loan (NSL)

Primary Care Loan (PCL)

PLEASE READ CAREFULLY BEFORE YOU COMPLETE THIS REQUEST:

1. Recipients of funds from the Department of Health and Human Services Federal programs referenced above (Health Professions Student Loan, Loans for Disadvantaged Students, Nursing Student Loan, and Primary Care Loan) are responsible for requesting and certifying to the institution from which they received the loan their eligibility for Deferment.

2. Deferments are only granted for specific activities (see Part II below). You must be participating in one of these activities to be eligible for deferment under this program. Borrowers must file deferment forms annually for each additional year of deferment. Borrowers must request deferments at least 30 days before the beginning of an activity that makes the borrower eligible for deferment. If the borrower is beginning the deferable activity during the grace period, the form is due 30 days before the repayment period (i.e., the due date of the first payment). If you fail to submit this form to your school 30 days prior to the payment due date, your school is required to consider your loan past due and must take action to collect as required by the program regulations.

3. The institution from which you received your Title VII or Title VIII loan funds may have their own Deferment Request form. Please contact your institution to see if they have and prefer you use their form.

4. It is your responsibility to immediately notify the institution from which you received the loan funds of anything that has change that might impact your Deferment eligibility, should the Deferment Request be granted.

5. While your Loan Servicer may contact you regarding the status of this Deferment Request, it is ultimately your responsibility to confirm your eligibility for Deferment. Your school is considered the lender for these loans, acting as an agent of the federal government. However, they may contract with an organization called a Loan Servicer to work with you during repayment.

6. These loans are not reflected on the National Student Loan Data System (NSLDS).

INSTRUCTIONS:

1. Complete Part I in its entirety, sign, and date.

2. Complete Part II by indicating the category under which you are applying to defer payments on your loan with this Deferment Request.

3. Complete Part III by taking to the appropriate Designated Official at your school, teaching hospital, or service organization, for completion and signature of Part III, based on your Deferment category selected in Part II.

4. Make a copy for your records.

5. Submit original signed request to your institution from which you received your loan funds or the Loan Servicer, taking note of when and where you submitted this Deferment Request. Refer to the information provided at your Loan Exit Interview for information on where to submit this Deferment Request. If you are unsure where, please contact the school. This request must be submitted prior to you receiving deferment.

6. Contact your institution or Loan Servicer after a designated period of time to confirm not only receipt of this Deferment Request, but its status.

7. If your circumstances change and you cease to become eligible for deferment status, please notify the school immediately upon termination of your status.

PART I: TO BE COMPLETED BY BORROWER

Name ________________________________________

Address ________________________________________

________________________________________

________________________________________

Phone ________________________________________

Email ________________________________________

Loan Program HPSL LDS NSL PCL

(Please circle one program above for which you are requesting a deferment.)

Discipline ________________________________________

Requested START Date of Deferment: _________ Requested END Date of Deferment: __________

mm/dd/yyyy mm/dd/yyyy

My signature below confirms that:

• I am requesting deferment of payments of both interest and principal on any HPSL, LDS, NSL, or PCL loan that I received while enrolled at the institution.

• I am certifying that I am or will be participating in the approved deferment activity indicated below.

• I understand it is my obligation to immediately notify the institution from which I received assistance of any change in my status that might change my eligibility for this Deferment.

Signature ________________________________________ Date ____________

mm/dd/yyyy

________________________________________________________________________________

PART II: SELECT A DEFERMENT ACTIVITY TYPE

In accordance with Section 722(c) of the Public Health Service Act, 42 CFR 57:210, periodic installments of principal and interest need not be paid, and interest shall not accrue, while the borrower meets any of the following conditions as referenced below:

Please select one of the conditions from the appropriate loan categories below to indicate under which eligibility criteria you are applying for this Deferment. If your condition is not listed below, you are not eligible for deferment:

Health Professional Student Loan (HPSL)

_____ Active Duty as a member of a uniformed service of the United States (maximum 3 years)

_____ Volunteer under the Peace Corps Act (maximum 3 years)

_____ Pursuing advanced professional training, including internship and residency (unlimited years)

_____ Leave of Absence to pursue related educational activity (maximum 2 years)

_____ Graduate fellowship program or related graduate educational activity (maximum 2 years)

Loans for Disadvantaged Students (LDS)

_____ Active Duty as a member of a uniformed service of the United States (maximum 3 years)

_____ Volunteer under the Peace Corps Act (maximum 3 years)

_____ Pursuing advanced professional training, including internship and residency (unlimited years)

_____ Leave of Absence to pursue related educational activity (maximum 2 years)

_____ Graduate fellowship program or related graduate educational activity (maximum 2 years)

Nursing Student Loan (NSL)

_____ Active Duty as a member of a uniformed service of the United States (maximum 3 years)

_____ Volunteer under the Peace Corps Act (maximum 3 years)

_____ Enrolled Full-Time or Half-Time in a collegiate nursing school (maximum 10 years)

_____ Pursuing advanced professional training in nursing, including training in nurse anesthetist. (maximum 10 years)

Primary Care Loan (PCL)

_____ Active Duty as a member of a uniformed service of the United States (maximum 3 years)

_____ Volunteer under the Peace Corps Act (maximum 3 years)

_____ Pursuing advanced professional training in Primary Care, including internships and residencies (unlimited years)

(Please note a residency program must be completed within 4 years of graduation from medical school.)

_____ Leave of Absence to pursue related educational activity (maximum 2 years)

_____ Graduate fellowship program or related graduate educational activity (maximum 2 years)

_________________________________________________________________________

PART III: TO BE COMPLETED BY DESIGNATED OFFICIAL

1. This section should be completed by a Designated Official who can verify your enrollment status (including any Leave of Absence) should you be requesting Deferment based on your advanced professional training status. This includes participation in internships, residencies and graduate fellowship programs.

Name and Contact Information for Authorizing Official at School or Teaching Hospital

Name ________________________________________

Title ________________________________________

School or Hospital ________________________________________

Address ________________________________________

________________________________________

________________________________________

Phone ________________________________________

Email ________________________________________

Program Name ________________________________________

This is to certify that the borrower’s program, as referenced in the appropriate category above began or will begin and is scheduled to end on the following dates:

Program Start Date: ___________ Scheduled Program Completion Date: __________

mm/dd/yyyy mm/dd/yyyy

Signature ________________________________________ Date __________

mm/dd/yyyy

2. This section should be completed by a Designated Official who can verify your military or Peace Corps status should you be requesting Deferment based on one of those categories.

Name and Contact Information for Uniformed Service or Peace Corps Official (for borrowers applying under Active Duty or Peace Corps eligibility criteria:

Name ________________________________________

Title/Rank ________________________________________

Service Organization ________________________________________

Address ________________________________________

________________________________________

________________________________________

Phone ________________________________________

Email ________________________________________

Location of Service ________________________________________

Borrower’s Uniformed Service Serial Number* _________________

Signature ________________________________________ Date __________

mm/dd/yyyy

* The uniformed services of the United States are the Army, Navy, Marine Corps, Air Force, Coast Guard, deployed National Guard, National Oceanic and Atmospheric Administration Corps, and the U.S. Public Health Service Commission Corps.

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form is subject to penalties which may include fines and imprisonment under Federal Statute.

____________________________________________________________

PART IV: TO BE COMPLETED BY THE INSTITUTION

This section should be completed by the institution from which you received the Federal Title VII or Title VIII funds, or the Loan Servicer under contract with the institution to service these loans.

Approved _____

Denied _____

Denial Reason

___________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date Request Processed ___________

mm/dd/yyyy

Date Borrower Notified __________

mm/dd/yyyy

Amount of Loan Deferred __________

Expiration Date of Approved Deferment Period _____________

Public Burden Statement: The purpose of this information collection request is to obtain information for the administrative requirements pertaining to the Health Professions Student Loan (HPSL), Loans for Disadvantaged Students (LDS), Primary Care Loan (PCL) and Nursing Student Loan Programs (NSL). Participating HPSL, LDS, PCL and NSL schools are responsible for determining eligibility of applicants making loans, and collecting monies owed by borrowers on their outstanding loans. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0047 and it is valid until XX/XX/202X . This information collection is required to obtain or retain a benefit (HPSL – Sections 721-722 and 725-735 of the PHS Act; LDS – Sections 721-722 and 724-735 of the PHS Act; PCL – Sections 721-723 and 725-735 of the PHS Act; NSL – Sections 835-842 of the PHS Act). The information is protected by the Privacy Act, but it may be disclosed outside the U.S. Department of Health and Human Services, as permitted by the Privacy Act and Freedom of Information Act, to Congress, the National Archives, and the Government Accountability Office, and pursuant to court order and various routine uses as described in the System of Records Notice 09-15-0038. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.