Page 1 of 5 **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 pe nalties 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 comp lete 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 Item s 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 .Page 2 of 5 

### 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 t** **hat 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 t he disabled person’s current diagnosis ?

______ ______________________________________ **I certify, to the best of my knowledge and belief and in my best medical judgment** **, that : (1)**  t hat 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 loa n principal o r 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 n ot 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 not ify my loan holder immediate ly 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/Representativ e**  **Signature** :

_______________

__________________

____ __________ **Date** :

___ ___ - ___ ___ - ___ ___ ___ ___ Name of Representative (if applicable):

_______________________________________________ Relationship to Borrower:

_ _________________________ Address of Representative:

_______________________________________________ Representative Telephone: (

________ )

________ - ________ _ _____Page 3 of 5 **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 you r 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, a nd 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 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) Pro** **gram** 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 extensio n 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. Capitaliz** **ation 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 4 of 5 **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: Th e 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 y our 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 deter mine 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 an d 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 p rogram 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 p rovide 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 CongressPage 5 of 5 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 requ ires 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, plea se contact your loan holder directly ( see Section 7 ) .