Forbearance 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 types 1 and 2: Applicable to federal Perkins, Nursing/Health profession, and selected Institutional loans. Benefit types 3 and 4: Applicable to Perkins loans. Benefit type 1 – I request forbearance on my Perkins loans because: (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 Department 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) 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 school. (Complete section 2 and 3) Benefit type 3 – I request economic hardship because: (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) Benefit type 4 – I request an unemployment deferment for a period of ____ month(s). 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 mad 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: Signature___________________________________ SS Number_____________________ Date________________ Day Phone_____________________ Evening Phone______________________ Cell Phone____________________ Marital Status_____________________ Dependents – Number_______ Age(s)___________________________ Heartland ECSI PO Box 1278 Wexford, PA  15090 11/22/1999