FORM under review 60 day notice OMB NO. 1845 - 0128 Exp Date: x /xx /20 xx See Burden Statement on Page 2 

# BORROWER DEFERMENT REQUEST FOR THE HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM Under Title VII, Part A, Subpart I, Public Health Service Act as amended (42 U.S.C. 292 - 292o) and Consolidated Appropriation Act, 2014

This form is authorized by Section 705(a)(2)(C) of the Public Health Service Act as amended. **WARNING: Any person who knowingly makes a false statement or misrepresentation in a HEAL transaction, bribes, or attempts to bribe a**  **Federal official, fraudulently obtains a Federal HEAL loan or commits any other illegal action in connection with a Federal H EAL loan is**  **subject to a fine or imprisonment under Federal statute.** 

# INSTRUCTIONS 1. Prov ide the address of your lender. 2. C omplete, sign and date Section 1. 3. Select a deferment type in Section 2. 4. F or an internship, residency, fellowship or primary care deferment, complete Section 3A. For a school, Peace Corps, voluntary service, National Health Service Corps, Indian healthcare, or military deferment, have an appropriate official (listed in Section 3B) complete Section 3B. 5. R eturn the form to the lender/servicer listed in Se ction 1 

## SECTION 1: BORROWER SIGNA **TURE** NAME OF BORROWER (Type or Print) ADDRESS (Number and Street) SOCIAL SECURITY NUMBER CITY STATE ZIP CODE 

### I request exemption from payment of principal and interest on my Federal HEAL loan(s). I agree to notify the lender of my def erment (or attendance) status annually, or more frequently if changes occur. I understand that installments of principal and interest need not be paid, but interest shall accrue and may, at the lender's option, be compounded according to the terms of my promissory note. BORROWER SIGNATURE (Required for all deferment types) Date 

### Borrower must provide name and address of lender/servicer. 

### RETURN DEFERMENT FORM TO LENDER OR SERVICER. NAME

**_____________________________________________________________________________________** ADDRESS

**________________________________________________________________ ____________________**  **-**

________________________________________________________________________________________________________________________ 

## SECTION 2: SELECT DEFERMENT TYPE Please make sure you are eligible for the deferment type you select. CHOOSE ONE ONLY **.** 

## I w ish to postpone my Federal HEAL loan payments because of: 

# □ 1. Full time attendance at a HEAL school or a school eligible to p articipat e in the Title IV Higher Education Act of 1965, as amended p rogram s 

# □ 2. Participation in an approved internship or residency (4 year limit if you received your Federal HEAL loan on or after 10/22/85 or if grace has expired) 

# □ 3. Full time participation in an approved fellowship training program or educati onal activity (2 year limit)* 

# □ 4. Full time voluntary service in the Peace Corps (3 year (limit) 

# □ 5. Full time voluntary service under the Title I Domestic Volunteer Volunteer Service Act of 1973 (VISTA/ACTION) (3 year limit) 

# □ 6. Service as a member of the National Health Service 

# □ 7. Full time active duty in the Armed Forces (3 year limit) 

# □ 8. Completed approved internship or residency training in

osteopathic general practice, family medicine, general internal m edicine, preventive medicine, or general pediatrics and practicing primary care (3 year limit) 

# □ 9. Graduate of Chiropractic school (1 year limit) 

# □ 10. Provide health car e services to Indians through any health program or facility funded in whole or part by the Indian Health Service for the benefit of Indians (Section 705(a)(2)(C) of the PHS Act (3 year limit for service starting 02/01/1999 or later).

* A FELLOWSHIP TRAINING or EDUCATIONAL ACTIVITY must be directly related to the discipline for which you received your Federal HEAL loan(s), and must begin within 12 months from the time you left your accredited internship or residency program. It mu st NOT be part of, an extension of, or associated with your in ternship or residency. In addition, the FELLOWSHIP TRAINING must be a formally established fellowship program. You mu st participate full time in research training or health care policy, and receive either no stipend, or a stipend not greater than that 

### for graduate and professional training under Public Health Service grants.

____________________________________________________________________________________________________________________ HEAL - 508**MPORTANT: COMPLETE DEFERMENT CERTIFICATION ON FIRST PAGE** 



### ___________________________________________________________________________________________________________ 

# SECTION 3: DEFERMENT CERTIFICATION A. Required for Deferm ent Types **2, 3** and **8** only (For deferment type **8** , indicate when and where primary care residency was completed.) PROGRAM BEGIN DATE (Month - Day - Year) 

### ______/______/______ PROGRAM END DATE (Month - Day - Year) 

### ______/______/______ PROGRAM NAME

HOSPITAL/INSTITUTION NAME PHONE NUMBER ( ) TYPE OF RESIDENCY SPECIALTY ADDRESS CITY STATE ZIP CODE 

### B. Required for Deferment Types **1, 4, 5, 6, 7, 9,** and **10** only. Authorized officials for each deferment type above are: **1** - school registrar: **4** and **5** - a certifying officer in the Division of Volunteer Support ACTION (W ashington, DC); **6** - Public Health Service Regional Office Project Officer for the National Health Service Corps; **7** - Military Commanding Officer; or **10 -**  certifying official familiar w ith the funding of the health program or facility. I certify that the information stated on this form reflects the current status of the borrow er or that the borrower graduated _____/_____ (month/year). I also verify that I am qualified to certify this document. The borrow er's deferment period begins on _____/___/_____



### _ (mon th/day/year) and ends on



### _ _____/___/_____. SIGNATURE OF AUTHORIZED OFFICIAL DATE PHONE NUMBER ( ) NAME OF AUTHORIZED OFFICIAL (Please print) TITLE HEAL SCHOOL CODE (i f applicable)
SCHOOL OR INSTITUTION NAME ADDRESS CITY STATE ZIP CODE



### __________________________________________________________________________________________________________________________



# REMEMBER: Send this form to lender/servicer listed in Section 1.

PRA Burden Statement: 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 OM B control number. T he valid OM B control number for this information collection is 1845 - 0128
. P ublic reporting burden for this collection of information is estimated to average 30 minutes response, including time for reviewing instructions, searching existing data sources, gatheri ng and maintaining the data needed, and completing and reviewing the collection of information. T he obligation to r espond to this collection is required to obtain or retain benefit (Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriation Act, 2014 ). I f you have comment or concerns regarding the status of yo ur i ndividual submission of this form, please contact the HEAL Program, U.S. Department of Education, 830 First Street NE, W ashington, DC, 20202 directly. [Note: Please do not return the completed form to this address.]
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