PRINT THIS FORM, COMPLETE, AND DELIVER TO THE ADDRESS LISTED ON THE FOLLOWING PAGE

REQUEST FOR DEFERMENT OF FEDERAL PERKINS (NATIONAL DEFENSE/DIRECT), INSTITUTIONAL & HEALTH PROFESSION STUDENT LOANS

PART I: SECTION A - TO BE COMPLETED BY BORROWER (See next page for Instructions)
NAME OR BORROWER (Last, First, Middle, Maiden) HOME PHONE


 WORK PHONE
ADDRESS (Street, City, State, ZIP Code)


 CHECK HERE IF NAME OR ADDRESS IS NEW
 Federal Perkins (NDSL)
 HPSL/PCL
 Nursing Loan		  Institutional Loan
 Pharmacy Loan
SIGNATURE OF BORROWER
X		 SOCIAL SECURITY NUMBER
SECTION B - DEFERMENT (See next page)
 This is to certify that I am/will be:  (Check appropriate items)
  Pursuing a course of study in an institution of
       higher education
  Internship/Residency		  Uniformed Health Services
 A member of the Armed Forces
     (Active Duty)		  Quarter
 Semester		  Half-time or more
 Graduate Fellowship
  In the Peace Corps/Vista
 FROM (MONTH, DAY AND YEAR)  TO (MONTH,DAY AND YEAR)
PART II: CERTIFICATION OF STATUS
The person named IS or WAS:
Enrolled as a student:		 I certify that the information stated in Part I Section B is true and correct.
 Quarter  In Peace Corps/Vista
 Semester  Member of Armed Forces
    (Active Duty)
 Half-time  Internship/Residency
SIGNATURE OF AUTHORIZED OFFICIAL
TITLE
DATE OFFICIAL SEAL OR STAMP
NAME OF INSTITUTION OF HIGHER EDUCATION, MILITARY ORGANIZATION, PEACE CORPS/VISTA OR CERTIFYING AGENCY.


 PHONE #
ADDRESS (CITY, STATE, ZIP CODE)
PART III: COMPLETED BY THE LENDING INSTITUTION (For office use only)
 APPROVED  DISAPPROVED
SIGNATURE OF APPROVING OFFICIAL

 DATE
THIS FORM IS INVALID WITHOUT
   BORROWER'S SIGNATURE
 SOCIAL SECURITY NUMBER
 BEGINNING AND ENDING DATES
     (No more than 1 year)
 COMPLETE CERTIFICATION		  








DEFERMENT
FEDERAL PERKINS (NATIONAL DEFENSE/DIRECT), HEALTH PROFESSION AND INSTITUTIONAL STUDENT LOANS
 
If you are a STUDENT pursuing a course of study in an institution of Higher Education, a member on Active Duty in the ARMED FORCES, or a PEACE CORPS/VISTA volunteer or on Internship/Residency, complete PART I, SECTION B.  Be sure to indicate in the boxes provided, the length of time you are eligible for deferment.  After signing the form, have your school registrar, commanding officer, Peace Corps, Vista official or graduate medical education official certify the form by completing PART II. (For certification: Peace Corps Volunteers should forward the form to Division of Volunteer Support, Peace Corps, Washington, D.C. 20625; Vista members should forward the form to Division of Field Operations, Washington, D.C. 20506.) NOTE:  DEFERMENT FOR INTERNSHIP/RESIDENCY CANNOT EXCEED 2 YEARS FOR FEDERAL PERKINS LOANS.		  















 
RETURN FORMS TO:
UNIVERSITY OF UTAH
INCOME ACCOUNTING AND STUDENT LOAN SERVICES
201 SOUTH 1460 EAST, RM 165
SALT LAKE CITY, UT 84112-9054
OFFICE  (801) 581-8786 or 1-800-444-8638 ext. 1-8786
FAX  (801) 581-4277