PRATT INSTITUTE
Request for HARDSHIP
Print Name:_________________________ Social Security Number:_________________________

I request a HARDSHIP on my Institutional Loan. I understand that all information and supporting documents given will be held in strictest confidence and will not be subject to dissemination outside requirements of Pratt Institute. I also understand that if granted, this HARDSHIP is for no more than six months duration during which time interest will continue to accrue.

1. EMPLOYMENT INFORMATION
	_____	I am unemployed
		Date continuous unemployment began:_______________
	_____	I have received the maximum allowable unemployment benefits
	_____	I did not work long enough to receive unemployment benefits
	_____	I am receiving monthly unemployment benefits totaling $_______________
		[Please attach a copy of your unemployment check stub]
	_____	I am receiving monthly public assistance in the amount of $_______________
		[Please attach documentation as proof of eligibility]

2. PERSONAL INFORMATION
	_____Married _____Single _____Separated/Divorced _____Widow(er)

3. MONTHLY INCOME/EXPENSES
	Income
	Total Monthly Income (from all sources, i.e., Checking account, Savings account, Child Support, Unemployment etc.) $__________
	Expenses
	Rent/Mortgage	$_______________	Car	$_______________
	Utilities	$_______________	*Other	$_______________
	Total Monthly Expenses	$_______________

	* Please use the back of this form in conveying any circumstances, not listed above, that you feel would have a bearing on your request for this HARDSHIP.

	I certify that all statements made above are true and correct. I also certify that I will immediately notify your office of any NAME, ADDRESS or EMPLOYMENT CHANGES which may occur after completing this HARDSHIP form.

Borrower's Signature:	______________________________	Date: _______________
Borrower's Address:	______________________________
	______________________________
Borrower's Telephone Number:	______________________________