Sigma Alpha Epsilon Foundation
Request for Forbearance/Hardship/Unemployment Deferment I understand that all information and supporting documents given will be held in strictest confidence and will not be subject to dissemination outside the requirements of the lending institution. I further understand that this arrangement will consist of reduced or deferred payments, as determined by the lending institution based on my financial situation. It may be necessary to make accelerated payments at the expiration of this arrangement to repay the loan within the maximum ten-year period.

Borrower's Name/Address:

Mail form to: Account Number:

Section 1 Applicable Benefits

	Benefit type 1 - I request forbearance on my SAE Foundation loans because (Select one from A-D & check 1 or 2 on E): for a period of _____ months. (A)____ My title IV SFA loan payments are equal to or greater than 20% of my total monthly income. (Complete section 2 and 3) (B)____ I am unable to make scheduled payments due to 'Poor Health' (temporarily - totally disabled). (complete section 2 and 4) (C)____ I am enrolled in a course of study that is part of an approved rehabilitation training program for disabled individuals. (Complete sections 2 and 4) (D)____ Caring for a dependent who is disabled. (Complete section 2 and 4) (E)Interest continues to accrue during this benefit type. For interest payment (1)____bill me monthly (2) ____bill me at end of my benefit. (We recommend paying interest monthly to avoid a lump sum payment at the end of this benefit type or forbearance)
	Benefit type 2 - I request a Temporary reduction of my monthly loan payment: Based on my financial situation, I will make monthly payments in the amount of $__________ for a period of _____ months. If approved, I agree to make repayment of this amount each month as a condition of this agreement, and that if payment is not made, my agreement may be terminated by the SAE Foundation. (Complete section 2 and 3)
	Benefit type 3 - I request economic hardship deferment for a period of ____ months because: Interest continues to accrue during the forbearance period. For interest payments (1) ____ bill me monthly (2) ____ bill me at the end of the forbearance. (A)____ I have been granted economic hardship for William D. Ford Federal Direct Student Loan (FDSL) or Federal Family Education Loan (FEEL) for the current period of time. (Satisfactory documentation is required) (B)____ I am receiving payment under Federal or State Public Assistance. (AFDC, Supplemental Security income, Food Stamps, or State Public Assistance). (Complete section 2 and 3) (C)____ My title IV SFA loan payments are equal to or greater than 20% of my total monthly income, and my monthly gross income minus my Title IV loan payments is less than 220% of the earnings of individuals on minimum wage, or 100% of the poverty income for a family of two. (Complete section 2 and 3)
	Benefit type 4 - I request an unemployment deferment for a period of ____ month(s). Interest continues to accrue during the forbearance period. For interest payments (1) ____ bill me monthly (2) ____ bill me at the end of the forbearance. 1.I am currently unemployed and actively seeking employment. In order to verify that I am actively seeking employment, I must register with an employment agency and have this form certified. 2.Certification by employment agency: I certify that the above-mentioned individual has been duty registered with this employment agency.

Name____________________________________________ Address_______________________________________________________

City___________________________________ State________________ Zip______________ Phone number_______________________

Section 2 Borrower Certification

I certify that all statements made are true and correct. I also certify that I will immediately notify the lending institution of any change in my employment status or significant change in my financial situation. I authorize a representative of the lending institution to obtain from my applicable parties' pertinent information in order to verify this application. Final responsibility for completion and return of this form to the institution rests with the borrower. This account will remain in status quo until this form is approved if this form is incomplete; it will be returned to the borrower.

Signature___________________________________ SS Number________________________ Date________________ Day Phone______________________ Evening Phone_______________________ Cell Phone_____________________ Marital Status______________________ Dependents - Number_________________ Age(s)______________________ Please list the name, address, and phone number of someone who will always know your whereabouts: Name ____________________________________________________________________________________________ Address __________________________________________________________________________________________ Day Phone______________________ Evening Phone________________________ Cell Phone_____________________

SAE Approvals

Date_________ - _________ Approved______Disapproved_______Official_______________________Date________

Months of forbearance ______ Bill interest monthly _____ Bill interest at the end of forbearance _____

Section 3 Income and Expenses

My Monthly Income		Student Loan Information
	*__________Gross Wages *__________Spouse's **_________Public Assistance **_________Unemployment **_________Child Support **_________Other Income **_________Workmen Comp $___________________Total		Type    Loan Amt     Mthly Pmt _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ Total    $_________$__________

*PLEASE FURNISH CHECK STUB **PLEASE FURNISH EVIDENCE

Section 4 Statement of Disability (Completed by Physician)

Patient's Name:________________________________ Relationship to Borrower:________________________ Date when symptoms first appeared:________________ Date accident occurred:_________________________	Subjective symptoms:_________________________________________________ Objective Symptoms :_________________________________________________ Diagnosis :_________________________________________________ If needed please attach a separate sheet of paper
Treatment
First visit date___________ Last visit date__________	Frequency of visit (Weekly, Monthly, Other)_______________________________
Progress
Present condition: Is patient: Recovered_____ Ambulatory____ Unchanged______ Bed Confined_______ Improved_______ House Confined_____ Retrogressed_______ Hospital Confined______
Extent of Disability
Is patient 'NOW' totally disabled for If no, when is or was the patient able to go to work Will patient be able to resume any work Indefinite Never	Any Occupation YES_____ NO_____ MM/DD/YY__________ MM/DD/YY__________ YES_____ NO_____ YES_____ NO_____ Regular Occupation YES_____ NO_____ MM/DD/YY__________ MM/DD/YY__________ YES_____ NO_____ YES_____ NO_____
If yes, is patient a suitable candidate for rehabilitation      Yes______ No________ Physician Name________________________________________ Address___________________________________________________ City______________________________________________________ State___________ Zip____________________ Phone Number__________________________________ Fax number_________________________________ Date___________________________________ Attending Physician Signature________________________________________________