Institutional Action Date_________ - _________ Approved______Disapproved_______Official_______________________Date________ Section 3 Income and Expenses My Monthly Income *__________Gross Wages *__________Spouse’s **_________Public Assistance **_________Unemployment **_________Child Support **_________Other Income **_________Workmen Comp $___________________Total Student Loan Information Type Loan Amt   Mthly Pmt   _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ _____ $_________$__________ Total $_________$__________ *PLEASE FURNISH CHECK STUB **PLEASE FURNISH EVIDENCE Section 4 Statement of Disability (Completed by Physician) Patient’s Name:_____________________________________ Subjective symptoms:_________________________________________________ Relationship to Borrower:_____________________________ Objective Symptoms :_________________________________________________ Date when symptoms first appeared:____________________ Diagnosis                   :_________________________________________________ Date accident occurred:_______________________________ 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: Recovered_____ Unchanged______ Improved_______ Retrogressed_______   Is patient: Ambulatory____ Bed Confined_______ House Confined_____ Hospital Confined______ Extent of Disability Any Occupation Regular Occupation Is patient ‘NOW’ totally disabled for YES_____ NO_____ YES_____ NO_____ If no, when is or was the patient able to go to work MM/DD/YY__________ MM/DD/YY__________ Will patient be able to resume any work MM/DD/YY__________ MM/DD/YY__________ Indefinite YES_____ NO_____ YES_____ NO_____ Never 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________________________________________________________