FEDERAL PERKINS STUDENT LOAN
ECONOMIC HARDSHIP & UNEMPLOYMENT DEFERMENT FORM INSTRUCTIONS
Complete the form in full. Print out this form and mail it to: Loans & Collections, MS 9023 Western Washington University 516 High Street Bellingham, WA 98225-9023
Your deferment form must be completed in full or the processing of your deferment may be delayed.
If you have any questions please contact WWU Loans & Collections (360) 650-4055.
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NDSL/FEDERAL PERKINS STUDENT LOAN APPLICATION FOR HARDSHIP/UNEMPLOYMENT DEFERMENT (You must fill out both sides of this form)
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Name: Address:
Account Number(s):
40682-
-01
Telephone: Date of Birth: Social Security No: Email:
(home) (work)
Spouse Name: Spouse SSN: Spouse Date of Birth: Past Due Amount:
Please read this entire form before you fill it out. I request deferment of my student loan(s) payments, beginning ________________. I meet the qualification(s) I have checked below, and I have attached the required documentation. I understand that the maximum benefit is three years, which will be granted to me in periods of not more than six months at a time. If I do not qualify for any of these benefits I would like to request a Forbearance _______ (Init) I choose to pay my interest: Monthly at the end of my Forbearance
Prolonged illness, starting ___________ and ending ___________. Attach explanation of how your health affects your ability to pay this loan(s). Provide physician statement of diagnosis, and submit this application. Unemployed since __________. Provide documentation such as proof that you are collecting unemployment benefits. I registered with the following public or private employment agency: Name of agency: Contact: Telephone: Address:
If you have not registered with an employment agency (attach explanation). Working part-time and unable to find full-time employment (full-time = 30 hours per week for three consecutive months). I have not worked full-time since _______________. I receive payment under a federal or state public assistance program, such as Aid to Families with Dependent Children, Supplemental Security Income, Food Stamps or state general public assistance. I have attached documentation that I am receiving these benefits. I work full-time (30 or more hours per week), and: My Total Monthly Gross Income (TMGI) does not exceed the federal minimum wage, or 100% of the poverty line for a family of two; or My TMGI is not greater than twice the federal minimum wage or the poverty line for a family of two and when I subtract the amount of payments I must make on all my federal education loans from my TMGI, the result is not more than greater of the federal minimum wage or the poverty line for a family of two; or The amount of payments I must make on all my federal education loans is at least 20% my TMGI, and the difference between my TMGI and the amount of payments I must make on my federal education loans is less than 220% of the minimum wage or the poverty line, whichever is greater. To determine your eligibility for deferment of payments provide the following: Total monthly gross income (the gross amount you receive from employment and other sources before taxes and other deductions): $_____________________. Lender: 1. 2. 3. 4. 5. Type of Loan: Amount Borrowed Monthly Payment
The Poverty Line for a family of two is determined each year by the Federal Government and published in the Federal Register. Effective February 2005, the Poverty Line income is $16,030 for Alaska, $14,760 for Hawaii, and $12,830 for all other states and District of Columbia.
INCOME & EXPENSES SUMMARY The following information is requested to determine your eligibility for hardship/unemployment deferment or forbearance. The information you provide will remain confidential, however, we reserve the right to use this information if collection efforts become necessary. 1. Marital Status: Single Married Widow(er) Separated/Divorced 2. Number of Dependents: Relationship: 5. Monthly Expenses: Rent/Mortgage Utilities Child Care Car Payments Other Vehicle(s) Insurance (Home, Health, Auto) Telephone Cellular Phone Food Credit Card(s) Other Charge Card(s) Medical Other:
Age:
3. Monthly Income from ALL Sources*: Gross Monthly Salary/Wages Spouse’s Monthly Salary/Wages Child Support Alimony/Support Unemployment Public Assistance Social Security/Veteran Stock, Bonds & Investments Total Monthly Income: 4. Checking Account Balance: 5. Savings Account Balance:
$0.00
Total Monthly Expenses:
$0.00
Attach documentation to substantiate all income and expense entries. EMPLOYMENT Borrower’s Employer: Name: Address: Telephone: Gross Monthly: Paid: Weekly Bi-Weekly Monthly Years on the job: Spouse’s Employer: Name: Address: Telephone: Gross Monthly: Paid: Weekly Bi-Weekly Monthly Years on the job:
I declare that the information given by me is true, correct and complete to my knowledge. I realize that my statements are subject to complete verification and that it is my responsibility to provide additional verification if requested. I understand that the information reported in this declaration would be used to determine my eligibility for alternative payment arrangements. I understand that a credit report will be generated in order to verify my expenses.
Signature: _______________________________________
Date: _____________________
You will be notified when your deferment or forbearance is approved. Return the completed Financial Statement to: Student Loans & Collections Office, MS 9023 516 High Street Bellingham, WA 98225-9023 FOR OFFICE USE ONLY Date Mailed:_______________________ Init:_________ Approved:____________________________________ Disapproved:_______________________________ Deferred from:___________________________ to __________________________________ Sent Verification:_______ Deferment Type: Hardship Unemployment Forbearance No. of Months:_________
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