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## MANDATORY FORBEARANCE REQUEST **MEDICAL OR DENTAL INTERNSHIP/RESIDENCY, NATIONAL GUARD DUTY, OR DEPARTMENT OF DEFENSE LOAN REPAYMENT PROGRAM**  **William D .**  **Ford Federal Direct Loan (Direct Loan) Program**  **/ Federal Family Education Loan (FFEL) Program**  OMB No . 1845-0018 DRAFT FORM Exp . Date XX/XX/XXXX

**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 . **SECTION 1: BORROWER IDENTIFICATION**  Please enter or correct the following information . **Check this box if any of your information has changed .**  SSN Name Address City, State, Zip Telephone – Primary Telephone – Alternate E- mail (optional) ___ ___ ___ - ___ ___ - ___ ___ ___ ___

_____________________________ _______ _______

____________________________________ _______

________________________ , _______ __________ (

____ ____ ___ )

___ _ ___ ____ - ___

_ _ ___ _________ (

_ ___ _ _ _____ )

_____

____ __ - _____

_ _ ___ _______

___________________________________________ **SECTION 2: FORBEARANCE**  **ELIGIBILITY** This forbearance request form covers three different forbearances . Carefully review the information for each forbearance type to determine whether you qualify for that forbearance . **1.** Check the type of forbearance you would like to receive : Stop making payments – Continue to Item 2 . Make smaller payments in the am ount of $____________ per month – Skip to Item 3 . **2.** I nterest will accrue on your l oan(s) during forbearance . You may pay the interest that accrues on your these loan(s) during forbearance . If you do not pay this interest, it will capitalize. Do you wish to make interest payments on your loan(s) during forbea rance ? Yes – Continue to Item 3 . No – Continue to Item 3 . **3.** You may receive this forbearance in 12-month increments . Would you like this forbearance end earlier? Yes – Continue to Item 4 . No – Skip to Item 5, 10, or 16 . **4.** Provide the date on which you want the forbearance to end and then continue to Item 5, 10, or 16 :

___ ___ - ___ ___ - ___ ___ ___ ___ **PART A. MEDICAL**  **OR DENTIAL INTERNSHIP/RESIDENCY** You only qualify for this forbearance if you do not qualify for a medical or dental internship/residency deferment. **5.** Have you been accepted to an internship/residency program? Yes – Continue to Item 6 . No – You are not eligible this forbearance . **6.** Did your program require, as a condition of admission, that you have a bachelor’s degree from an institution of higher education? Yes – Continue to Item 7 . No – You are not eligible this forbearance . **7.** Is your internship/residency program a program in which you will receive training under supervision? Yes – Continue to Item 8 . No – You are not eligible this forbearance . **8.** Will completion of this program lead to a degree or certificate awarded by an institution of higher education, a hospital, or a health care facility that offers postgraduate training? Yes – Have an authorized official complete Section 3 and then complete Section 4 No – Continue to Item 9 .Page 2 of 5 

### Borrower Name: ______________________________ Borrower SSN:

**___ ___**  **___ -**  **___ ___**  **- ___**  **___ ___**  **___ SECTION 2:**  **FORBEARANCE ELIGIBILITY**  **(CONTINUED) 9.**  Will completion of the program be required by you can begin professional practice or service? Yes – Have an authorized official complete Section 3 and the n complete Section 4. In addition, you must attach a separate statement form the appropriate state licensing agency certifying this requirement. No – You are not eligible this forbearance . **PART B**  **. NATIONAL GUARD DUTY**  You only qualify for this forbearance if you do not qualify for a military service deferment. **10.** Are you a member of the National Guard? Yes – Continue to Item 11 . No – You are not eligible this forbearance . **11.** Are you engaged in active State duty under which a governor activated you based on state statute or policy? Yes – Continue to Item 12 . No – Skip to Item 13 . **12.** Is your service being paid for with State funds? Yes – Skip to Item 15 . No – Continue to Item 13 . **13.** Are you engaged in active State duty under which a governor activated you with the approval of the President or the U.S. Secretary of Defense? Yes – Continue to Item 14 . No – You are not eligible for this forbearance . **14.** Is your service being paid for with Federal funds? Yes – Continue to Item 15 . No – You are not eligible for this forbearance . **15.** Were you activated not more than 6 months after the last date on which you were enrolled in school at least half time? Yes – Have an authorized official complete Section 3 and then complete Section 4. No – You are not eligible for this forbearance. **PART C** **. DEPARTMENT OF DEFENSE LOAN REPAYMENT**  **PROGRAM 16.**  Are you performing service that qualifies you for partial repayment of your loan(s) under the Department of Defense Loan Repayment Program authorized under 10 U.S.C. 2171? Yes – Have an authorized official complete Section 3 and then complete Section 4. No – You are not eligible for this forbearance . **SECTION 3**  **: AUTHORIZED OFFICIAL’S CERTIFICATION**  **Note: As an alternative to completing this section, you may attach**  **separate documentation from an authorized official that includes all of the information requested below** **, or, for the National Guard forbearance, a copy of the borrower’s orders**  . **17.** Did the borrower sel ect “yes” in Item 8, 9, 15, or 16 ? Yes – Complete Items 18 through 26 . No – Do not complete this section . **18.** The program/service begins/began on :

___ ___ - ___ ___ - ___ ___ ___ ___ **19.** The program/service is expected to end/ended on :

___ ___ - ___ ___ - ___ ___ ___ ___ **I certify, to the best of my knowledge and belief, that :**   The borrower named above is/was engaged in the service indicated in Section 2;  That the borrower and the service meet all conditions indicated by the borrower’s responses in Section 2; and  That the information that I have provided in Section 3 is accurate. **20.** Name of Institution/Organization :

_ _________

_____ _____ ______________________________ _________

________ **21.** Address:_____________________________________ **22.** Name/Title:__________________________________ **23.** Signature:____________________________________ **24.** City, State, Zip Code:

______________ , ____ _______ **25.** Telephone: (

________ )

________ - ________ _ _____ **26.** Date:

___ ___ - ___ ___ - ___ ___ ___ ___Page 3 of 5 

### Borrower Name: ______________________________ Borrower SSN:

**___ ___**  **___ -**  **___ ___**  **- ___**  **___ ___**  **___ SECTION**  **4 :**  **BORROWER REQUEST**  **UNDERSTANDINGS CERTIFICATIONS, AND AUTHORIZATION**  **I request** a forbearance based on my service, as indicated in Section 2. If I am eligible for a deferment based on my service, I request that my loan hold grant me a deferment based on that service. **I understand that: 1.**  I am not required to make payments of loa n principal o r interest during my forbearance . **2.** My forbearance will begin on the date the program or service that qualifies for the forbearance began, as certified by the authorized official. **3.** My forbearance will end on the earlier of the date I am no longer eligible for the forbearance, 12 months from the date specified in Item 18, or the date I indicated in Item 4 . **4.** My forbearance will only be granted in 12- month increments and I must reapply for the forbearance if I continue to meet the eligibility requirements and want to ext end my forbearance. **5.** If my forbearance does not cover all my past due payments, my loan holder may grant a forbearance for all payments due before the begin date of my deferment. **6.** My loan holder may grant a forbearance for up to 60 days for the collection and processing of documentation related to my forbearance request. Interest that accrues during this forbearance will not be capitalized. **I certify that: 1.**  The information I have provided on this form is true and correct. **2.** I will provide additional documentation to my loan holder, as required, to support my forbearance status. **3.** I will not ify my loan holder immediate ly when my qualification for the forbearance ends. **4.** I have read, understand, and meet the eligibility requires of the forbearance for which I have applied. **I authorize** the entity to which I submit this request (i.e., the school, the lender, the guaranty agency, the U.S. Department of education, and their re spective agents and contractors) to contact me regarding my request or my loan(s) including repayment of my loan (s), at the number that I provide on this form or any future number that I provide for my cellular telephone or other wireless device using auto mated telephone dialing equipment or artificial or prerecorded voice or text messages. **Borrower’s Signature** : _____________________________________________ **Date** :

___ ___ - ___ ___ - ___ ___ ___ ___ **SECTION 5 :**  **INSTRUCTIONS** Type or print using dark ink. Enter dates as month -day-year (mm -dd -yyyy). Use only numbers. Example: March 14, 2015 = 03 - 14-2015. An authorized official must either complete Section 4 or attach the organization’s own signed certification listing the required infor mation. Include your name an account number on any documentation that you are required to submit with this form. If you need help completing this form, contact your loan holder. 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. **SECTION 7: WHERE TO SEND THE COMPLETED FORM** Return the completed form to : If you need help completing this form, call:Page 4 of 5 **SECTION 6 :**  **DEFINITIONS** An **authorized official** is an internship/residency program official (for medical and dental internships and residencies); or an authorized official from the Department of Defense (the Loan Repayment Program); or commanding o r personnel officer (for National Guard State Duty) **Capitalization** is the addition of unpaid interest to the principal balance of your loan. As a result of capitalization, more interest may accrue over the life of the loan and the monthly payment amount may be higher. The chart below (Table 1) provides estimates, for a $15,000 unsubsidized loan balance at a 6.8% interest rate, of the monthly payments due following a 12 - month deferment that started when the loan entered repayment. It compares the effects of paying the interest as it accrues, capitalizing the interest at the end of the deferment, and capitalizing interest quarterly and at the end of the deferment. Please note that the U.S. Department of Education (the Department) and many other holders do not capitalize interest on a quarterly basis . The actual loan interest cost will depend on your interest rate, length of the deferment, a nd frequency of capitalization. A **deferment** is a period during which you are entitled to postpone repayment of the principal balance of your loan(s). Interest does not accrue during a deferment on a Direct Subsidized Loan, a Direct Subsidized Consolidation Loan, a subsidized Federal Stafford Loan, or, in some cases, the su bsidized portion of a Federal Consolidation Loan (see Note). Interest does accrue during a deferment on a Direct Unsubsidized Loan, a Direct PLUS Loan, a Direct Unsubsidized Consolidation Loan, an unsubsidized Federal Stafford Loan, a Federal PLUS Loan, or a Federal SLS Loan. **Note:** Interest does not accrue on a Federal Consolidation Loan during a deferment only if: **(1)** the application for the loan was received by your loan holder on or after January 1, 1993, but before August 10, 1993; **(2)** the application was received by your loan holder on or after August 10, 1993, and the loan includes **only** subsidized Federal Stafford Loans; or **(3)** the application was received by your loan holder on or after November 13, 1997, in which case interest does not accrue on the portion of the Federal Consolidation Loan that paid a subsidized Direct Loan or FFEL Program loan(s). The **Federal Family Education Loan (FFEL) Program**  includes Federal Stafford Loans, Federal PLUS Loans, Federal Consolidation Loans, and Federal Supplementa l Loans for Students (SLS). A **forbearance** is a period during which you are permitted to temporarily postpone making payments, allowed an extension of time for making payments, or temporarily allowed to make smaller payments than scheduled. The **holder** of your Direct Loan Program loan(s) is the Department . The holder of your FFEL Program loan(s) may be a lender, guaranty agency, secondary market, or the Department. 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. **Table 1. Capitalization**  **Chart Treatment of Interest Accrued**  **During Deferment Loan**  **Amount Capitalized** 

**Interest Principal**  **Monthly Pmt.**  **Num.**

**Pmts. Total** 

**Repaid Total** 

**Interest Paid**  Interest is paid $15,000.00 $0.00 $15,000.00 $172.62 120 *$21,736.55 $6,730.66 Interest is capitalized at the end of deferment $15,000.00 $1,022.09 $16,022.09 $184.38 120 $22,125.94 $7,119.64 Interest is capitalized quarterly during deferment and at the end of deferment $15,000.00 $1,048.51 $16,048.51 $184.69 120 $22,162.41 $7,156.10

*Total amount repaid includes $1,022.09 of interest paid during the 12

- month period of deferment.Page 5 of 5 **SECTION 8**  **: IMPORTANT NOTICES**  **Privacy Act Notice .**  The Privacy Act of 1974 (5 U . S . C . 552a) requires that the following notice be provided to you: 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 authoriti es 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 Federal Family Education Loan (FFEL) Program or the William D . Ford Federa l Direct Loan (Direct Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate . The principal purposes for collecting the information on this form, including your SSN, are to ve rify 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 loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) becomes delinquent or defaults . We also use your SSN as an account identifier and to permit you to access your account information electronically . The information in your file may be disclosed, on a caseby-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices . The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with fed eral student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default . To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies . To provide financial aid history information, disclosures may be made to educational institutions . To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies . To provide a standardized method for educational institutions to efficiently submit student enrollment statuses, disclosures may be made to guaranty agencies or to financial and educational institutions . To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies . In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation . If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action . We may send information to members of Congress if you ask them to help you with federal student aid questions . In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues . If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U . S . C . Chapter 71 . Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records . Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards . Disclosures may also be made to qualified researchers under Privacy Act safeguards . **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 i s 1845 -001 8 . Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing a nd reviewing the collection of information . The obligation to respond to this collection is required to obtain a benefit in accordance with 34 CFR 682. 211 or 685.205 . If you have comments or concerns regarding the status of your individual submission of th is form, please contact your loan holder directly ( see Section 7 ) .