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U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES (DHHS)
PUBLIC HEALTH SERVICE
(PHS)
HEALTH RESOURCES AND SERVICES ADMINISTRATION
BUREAU OF HEALTH
PROFESSIONS
GUIDANCE
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HEALTH
PROFESSIONS STUDENT LOAN PROGRAM
MASTER PROMISSORY NOTE
(SINGLE OR
MULTI-YEAR)
FOR LOANS MADE ON OR AFTER
JULY 1,
2004
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I, Maxwell LaSmart, hereinafter called the Borrower, promise to pay to Sample University,
hereinafter called the Institution located at MyTown, PA, the sum of such amounts as may from time to time
be advanced to me with interest at the rate of Five (5) percent per annum together with all attorney's fees, collection agent costs, and
other related costs and charges for the collection of any amount not paid when in default according to the terms of this Promissory Note.
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| The Borrower and Institution further understand and agree that:
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| 1. |
Consolidation (42 CFR 57.208): If the
Institution makes more than one loan, with the same repayment terms, to
the Borrower under the Health Professions Student Loan program, the sum of
the amounts advanced to the Borrower shall be consolidated for purposes of
repayment. Each payment made by the Borrower to the Institution shall be
applied first to interest which has accrued on the unpaid principal
balance and then to the principal sum of the total loan.
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| 2. |
Repayment (Section 722 Public Health Service Act, 42
CFR 57.210): |
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a. Repayment shall be made in equal or graduated periodic installments
within the repayment period, except that the Institution may require
repayment to be made in an amount equal to not less than $40 per
month. The repayment period begins one year after the Borrower
ceases to be a full-time student at a school eligible to participate
in the Health Professions Student Loan program. The repayment period
shall not be less than ten years, nor more than 25 years, at the
discretion of the Institution. Periods of authorized deferment are not
included as part of the repayment period.
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b. The terms and conditions of repayment shall be set forth in a
separate repayment period schedule which is approved by the Institution
and agreed to by the Borrower. Payments under the repayment schedule shall
be made to the Institution or its representative no less often than
quarterly, except that if the Borrower is more than 60 days past due on a
payment, the remaining balance of the loan shall be repaid on a monthly
basis.
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| 3. |
Interest (Section 722 Public Health Service Act, 42
CFR 57.208): Interest shall accrue from the beginning of the
repayment period.
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| 4. |
Deferment (Section 722 Public Health Service Act, 42
CFR 57.210): Periodic installments of principal and interest need
not be paid, and interest shall not accrue, while the Borrower: (a) serves
on active duty as a member of a uniformed service of the United States,
for up to three years; (b) serves as a volunteer under the Peace Corps
Act, for up to three years; (c) pursues advanced professional training,
including internships and residencies; (d) pursues a full-time course of
study at a health professions school eligible for participation in the
Health Professions Student Loan program; (e) leaves the Institution, with
the intent to return to the Institution as a full-time student, to engage
in a full-time educational activity which is directly related to the
health profession for which the Borrower is preparing, as determined by
the Secretary of Health and Human Services (the Secretary), for up to two
years; and (f) participates in a fellowship training program or a
full-time educational activity which is directly related to the health
profession for which the Borrower prepared at the Institution, and is
engaged in by the Borrower within 12 months after the completion of the
Borrower's participation in advanced professional training (described in
4(c) above) or prior to the completion of the Borrower's participation in
such training, for up to two years.
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| 5. |
Prepayment (Section 722 Public Health Service
Act): The Borrower may, at his or her option and without penalty,
prepay all or any part of the principal and accrued interest at any time.
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| 6. |
Exit Interview (42 CFR 57.210): The Borrower
agrees to attend an exit interview prior to completing or terminating
full-time student status at the Institution.
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| 7. |
Default (42 CFR 57.208): If the Borrower fails
to make an installment payment when due or fails to comply with any other
term of this Promissory Note, the loan will be considered in
default.
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| 8. |
Late Charge (Section 721 Public Health Service Act, 42
CFR 57.210): The Institution shall assess a late penalty charge
for failure of the Borrower to pay all or any part of an installment, or
for failure to file satisfactory evidence of entitlement to deferment, if
so entitled, at a rate, not to exceed an amount equal to 6 percent as
determined by the Institution of the amount of such installment, on loans
more than 60 days past due.
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| 9. |
Acceleration (42 CFR 57.208): If the Borrower
fails to make a scheduled repayment or fails to comply with any other term
of this Promissory Note, the entire unpaid balance of the loan, including
interest due and accrued and any applicable penalty charges, will, at the
option of the Institution, become immediately due and
payable.
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| 10. |
Credit Bureaus (42 CFR 57.210): The
Institution may disclose the Borrower's loan, and any other relevant
information, to credit bureaus. If the Borrower is more than 120 days past
due in making a scheduled repayment, the Institution will disclose the
Borrower's delinquent status, and any other relevant information, to
credit bureaus.
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| 11. |
Collection Agents, Litigation, and Withholding of
Services (Section 722 Public Health Service Act, 42 CFR 57.210):
If the Borrower fails to make a scheduled repayment, or fails to comply
with any other term of this Promissory Note, the Institution may: (a)
refer the Borrower's loan to a collection agent for further collection
efforts; (b) initiate legal proceedings against the Borrower; (c) withhold
Institutional services, such as transcripts and letters of recommendation,
from the Borrower; (d) refer the Borrower's loan to the Secretary for
collection assistance, including offset of Federal salaries; and (e)
obtain the Borrower's address from the Internal Revenue Service through
the Secretary, if the Institution has no current address for the Borrower.
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| 12. |
Death or Disability (42 CFR 57.211): In the
event of the Borrower's total and permanent disability or death, the
unpaid indebtedness remaining on the Promissory Note shall be canceled.
Subject to the regulations of the Secretary, the Institution may assess a
charge on the Borrower's loan to cover the costs of insuring against death
or disability cancellations.
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| 13. |
General: The Borrower will promptly inform the
Institution of any change in name or address after he or she ceases to be
a full-time student at the Institution. The terms of this Promissory Note
shall be construed according to the Federal statute and regulations
governing the administration of the Health Professions Student Loan
program, copies of which shall be kept by the
Institution.
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Notice About Subsequent Loans Made Under This Master Promissory
Note
This Note authorizes the Institution to disburse multiple loans during
the multi-year term of this Note upon the Borrower's request and upon the
Institution's determination of the Borrower's loan eligibility.
Subsequent loans may be made under the Note for the same or subsequent
periods of enrollment at this Institution. The Institution however, may at
its discretion, close this Note at any time and require the Borrower to
sign a new Note for additional disbursements. If the Institution chooses
to make subsequent loans under this Note, no such loans will be made after
the earliest of the following dates: (i) the date this Institution
receives the Borrower's written notice that no further loans may be made
disbursed under this note; (ii) the date of withdrawal from the
Institution by the Borrower.
Any amendments to the Public Health Service Act governs the terms of
any loans disbursed on or after the effective date of such amendment, and
such amended terms are hereby incorporated into this
Note. |
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NOTICE: The Institution must require security or endorsement if the
Borrower is a minor and if, under the applicable State law, the Note
signed by him or her would not create a binding obligation. The
Institution may not require security or endorsement in any other
circumstances. The Institution shall supply a copy of this Note to the
Borrower.
WARNING: Any person who knowingly makes a false statement or
misrepresentation in obtaining these funds is subject to penalties which
may include fines and imprisonment under Federal statute.
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01/01/2012
(Date) |
Maxwell LaSmart
(Signature of Borrower)
111 Main Street
(Address 1)
(Address 2)
MyTown PA 11111
(City/State/Zip)
000-00-0000 ***-**-0000
(Social Security Number)
07/14/1986
(Date of Birth)
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Rev 5/04
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