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:

Heartland ECSI
P.O. Box 1278
Wexford, PA 15090


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________________________________________________