PRATT INSTITUTE
200 Willoughby Avenue
Brooklyn, NY 11205
PERKINS/PRATT LOAN DEPT ________________________________________
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Account/SSN _____________________________

Physician's Affidavit of Temporary Total Disability

Please have your physician complete the affidavit and return it along with your deferment form to our office.

Under the National Direct/Perkins Student Loan Program, administered by the United States, Department of Education, a borrower is entitled to have periodic installment payments of principal deferred for up to three years, during which the borrower is temporarily totally disabled, or during which the borrower is unable to secure employment because he or she is caring for a spouse/dependent who is temporarily totally disabled. To qualify for this deferment, a borrower must provide the lender who issued the loan with an affidavit of a qualified physician, certifying the borrower's or the spouse's/dependent's disability.

The following affidavits are for the purpose of establishing the eligibility of a National Direct/Perkins Student Loan borrower to obtain a deferment for temporary total disability and are in a form acceptable for the United States Department of Education.

1.   If the patient is a borrower of a National Direct/Perkins Loan: I certify that, in my best professional judgment, my patient ______________________________ is temporarily totally disabled as a result of illness or injury and is unable either to attend school or to be gainfully employed. The nature of this patient's illness is ______________________________. The patient's temporary total disability began on _______________. I anticipate that this patient will recover from this disability to the extent that he or she will be able to either attend school or to be gainfully employed by ______________________________.

I am legally authorized to practice medicine/osteopathy in the State of ____________________. I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

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Signature or Physicians (M.D. or D.O.)     License #			Date
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Physician (Please print name (M.D. or D.O.))
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Street Address
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City	State	Zip Code
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Telephone Number			(See reverse for spouse or dependent)

2.   If the patient is the spouse/dependent of a National Direct/Perkins Student Loan borrower: I certify that, in my best professional judgment, my patient ______________________________ , who is the spouse/dependent (circle one) of ______________________________, is temporarily totally disabled "requiring continuous nursing or other services from the borrower for at least three months because of illness or injury." The nature of this patient's illness is ______________________________. This patient's temporary total disability began on _______________. I anticipate that this patient will recover from this disability to the extent that he or she will no longer require continuous nursing or other similar services by ______________________________.

I am legally authorized to practice medicine/osteopathy in the State of ____________________. I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

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Signature or Physicians (M.D. or D.O.)     License #			Date
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Physician (Please print name (M.D. or D.O.))
________________________________________________
Street Address
________________________________________________
City	State	Zip Code
________________________________________________
Telephone Number

According to the Federal Register , December 1, 1987, Section 674.34 and 674.35 temporary total disability deferment may be granted to you or your spouse if your loan was made on or after October 1, 1980 and prior to June 30, 1993. The provision for care of a dependent is only if your loan was made on or after July 1, 1987, with a nine-month grace period, and prior to June 30, 1993.

Sincerely,

Student Loan Representative