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 TDIS

TEMPORARY TOTAL DISABILITY DEFERMENT REQUEST

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family 

Education Loan (FFEL) Program

OMB No. 1845-0011

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: DEFERMENT ELIGIBILITY

Maximum eligibility for this deferment is 36 months. A physician’s certification is required for each 6-month period of 

deferment based on a temporary total disability.

1. Interest that accrues on unsubsidized loans during 

deferment will capitalize at the end of the deferment. 

Would you like to make interest payments on your 

unsubsidized loans during the deferment?

Yes – Continue to Item 2.

No – Continue to Item 2.

2. Are you temporarily totally disabled?

Yes – Continue to Item 3.

No –Skip to Item 7.

3. Are you unable to work and earn money or go to 

school?

Yes – Continue to Item 4.

No – You are not eligible for this deferment.

4. Are you applying for this deferment based on an 

illness or injury that existed before you applied for 

your loan(s)?

In the case of a Consolidation Loan, answer this 

question based on injuries or illnesses that existed at 

the time you obtained the loans you consolidated.

Yes – Continue to Item 5.

No – Skip to Item 6.

5. Has that illness or injury substantially deteriorated 

since you received your loan(s)?

Yes – Continue to Item 6.

No – You are not eligible this deferment.

6. Are you requesting this deferment based on an 

uncomplicated pregnancy?

Yes – You are not eligible for this deferment.

No – Have a physician complete Section 3 and then 

continue to Section 4.

7. Are you caring for a spouse or dependent who is 

temporarily totally disabled?

Yes – Continue to Item 8.

No – You are not eligible for this deferment.

8. Does your spouse or dependent have an injury or 

illness that requires at least 90 days of continuous 

nursing or similar care from you?

Yes – Continue to Item 9.

No –You are not eligible for this deferment.

9. Does the care you are providing prevent you from 

securing full-time employment (see Section 6)?

Yes – Continue to Item 10.

No –You are not eligible for this deferment.

10. Are you requesting this deferment based on your 

spouse’s or dependent’s uncomplicated pregnancy?

Yes – You are not eligible for this deferment.

No – Continue to Items 11 - 12

11. What is the full name of the spouse or dependent?

____________________________________________

12. What is the relationship between you and the 

individual named in Item 11?

____________________________________________

Have a physician complete Section 3 and then 

continue to Section 4.
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Borrower Name: ______________________________ Borrower SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 3: PHYSICIAN’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.

13. Did the borrower select “no” in Item 6?

Yes – Continue to Item 14.

No – Skip to Item 15.

14. Is the borrower unable to work and earn money or 

attend school for at least 60 days because of a 

medically determinable impairment?

Yes – Skip to Item 17.

No – Do not complete this section.

15. Did the borrower select “no” in Item 10?

Yes – Continue to Item 16.

No – Do not complete this section.

16. Does the borrower’s spouse or dependent require 

continuous nursing or similar care for a period of at 

least 90 days?

Yes – Continue to Item 17.

No – Do not complete this section.

17. When did the disabled person meet the criteria in 

Item 14 or 16?

___ ___ - ___ ___ - ___ ___ ___ ___

18. When is the disabling condition or care expected to 

end?

___ ___ - ___ ___ - ___ ___ ___ ___

19. What is the disabled person’s current diagnosis?

____________________________________________

I certify, to the best of my knowledge and belief and in my best medical judgment, that: (1) that the information that I 

have provided in Section 3 is accurate and (2) I am a doctor of medicine or osteopathy who is legally authorized to 

practice.

20. Name:_______________________________________

21. Address:_____________________________________

22. City, State, Zip Code:______________ , ____ _______

23. Signature:____________________________________

24. State where authorized to practice: ______________

25. Professional License Number: ____________________

26. Telephone: ( ________ ) ________ - ______________

27. Date: ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 4: BORROWER REQUEST, UNDERSTANDINGS CERTIFICATIONS, AND AUTHORIZATION

I request that my loan holder deferment repayment on my loans while I am temporarily totally disabled or while I am 

caring for a spouse or dependent who is temporarily totally disabled.

I understand that: (1) I am not required to make payments of loan principal or interest during my deferment; (2) My 

deferment will begin on the date the deferment condition began and will end on the earlier of the date that the 

condition that qualifies me for the deferment ends or the date it is expected to end, as certified by the physician. 

However, my deferment will last no longer than 6 months after the date of my physician’s certification; (3) If my 

deferment 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; (4) My loan holder may grant a forbearance for up to 60 days for the collection 

and processing of documentation related to my deferment 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 deferment status; (3) I will notify my loan holder 

immediately when my qualification for the deferment ends; (4) I have read, understand, and meet the eligibility requires 

of the deferment 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 respective 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 automated telephone dialing equipment or artificial or 

prerecorded voice or text messages.

Borrower/Representative Signature: 

_______________________________________________ 

Date: ___ ___ - ___ ___ - ___ ___ ___ ___

Name of Representative (if applicable):

_______________________________________________ 

Relationship to Borrower: __________________________

Address of Representative:

_______________________________________________ 

Representative Telephone:

( ________ ) ________ - ______________
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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. 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 6: DEFINITIONS

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, and 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 subsidized 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 

Supplemental 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.

Full-time employment is defined as working at 

least 30 hours per week in a position expected to last at 

least 3 consecutive months.

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.
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SECTION 7: WHERE TO SEND THE COMPLETED FORM

Return the completed form to: If you need help completing this form, call:

SECTION 8: ELIGIBILITY REQUIREMENTS

You are eligible for this deferment if, in addition to meeting the criteria below, you answered “no” to Item 6 or 

10.

For Direct Loan borrowers, you must have had an outstanding balance on a FFEL Program loan that was first 

disbursed before July 1, 1993 when you obtained your first Direct Loan.

For FFEL Program borrowers, you must have had an outstanding balance on a FFEL Program loan that was first 

disbursed before July 1, 1993 when you received your first FFEL Program loan on or after July 1, 1993.

SECTION 9: 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 authorities 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 Federal 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 verify 

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 

case-by-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 federal 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 
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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 is 

1845-0011. Public reporting burden for this collection of 

information is estimated to average 10 minutes per 

response, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining 

the data needed, and completing and reviewing the 

collection of information. The obligation to respond to this 

collection is required to obtain a benefit in accordance 

with 34 CFR 682.210 or 685.204. If you have comments or 

concerns regarding the status of your individual 

submission of this form, please contact your loan holder

directly (see Section 7).