First Name: Last Name: MI SID: -or- Last 4 of SSN Current Mailing Address: City: State: Zip: Phone Number: Cell Phone Number:

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1 Economic Hardship/Unemployment Deferment or Forbearance Request First Name: Last Name: MI SID: -or- Last 4 of SSN Current Mailing Address: City: State: Zip: Phone Number: Cell Phone Number: You do not need to complete every question Start with question #1 and follow the directions. ** THIS WORKSHEET MUST BE RETURNED WITH OTHER REQUIRED DOCUMENTS** 1 Have you been granted an Economic Hardship/Unemployment Deferment on another federal student loan program (e.g. Stafford, PLUS or other Perkins Loan) for the same time period for which you are requesting this deferment? Yes. That deferment covers the time period starting / / and ending / /. Documentation of current loan status is required. *Documentation must include start and end dates of approved deferment. Please complete Questions 6 & 10. No. Continue to Question 2. 2 Are you receiving payment under a Federal or State public assistance program, such as Temporary Assistance to Needy Families, Supplemental Security Income, or Food Stamps? Yes. I began receiving these benefits on / /. Send your most recent determination or other verification. Go Directly to Question 6. No. Continue to Question 3. 3 Are you unemployed or working less than 30 hours per week? I am unable to find, but actively seeking full-time employment. Go directly to Question 9. I am unable to work due to Poor Health. Go directly to Question 8. No. Continue to Question 4. 4 Are you working full-time and earning a total monthly gross income that does not exceed per month, which is equal to someone earning minimum wage? *The current hourly minimum wage is available at My Monthly Gross income is $ Yes. I have been earning minimum wage or less since / /. Send your last two (2) pay stubs and evidence of any other income. Continue to Question 10. No. Continue to Question 5. 1 P a g e

2 To complete the rest of this worksheet you will need information on your *monthly gross income from employment and other sources. You may also need information on your Federal Education Loans. *Monthly Gross income is your income before taxes or other deductions, not including spouse s income. 5 Are you working full-time and earning a total monthly gross income that is at or below the poverty line? 201 Health & Human Services Poverty Guidelines Persons in Family 48 Contiguous States and D.C. Alaska Hawaii 1 $11,670 $14,580 $13, ,730 19,660 18, ,790 24,740 22, ,850 29,820 27, ,910 34,900 32, ,970 39,980 36, ,030 45,060 41, ,090 50,140 46,110 For each additional person, add 4,060 5,080 4,670 *Annual poverty line guidelines, as defined by Section 673(2) of the Community Service Block Grant Act, are available at poverty. Yes. My total monthly gross income has been less than the annual poverty line since / /. Send your last two (2) pay stub and evidence of any other income. Continue to Question 10. No. Continue to Question 6. 6 If you answered NO to question #1, and have not been granted an economic hardship/ or unemployment forbearance, continue with question #6. I am having economic hardship and would like to request an economic hardship/or unemployment deferment. *It is the borrower s responsibility to attach dated evidence of income/and expenses listed below. *Please attach a copy of your check stub providing evidence of monthly income. Statement of Borrower Income & Expenses*: My Monthly Income Gross Wages Spouse s Gross Wages Public Assistance Unemployment Child Support Other Income Workmen s Compensation My Monthly Expenses Mortgage/Rent Car Expenses Credit Card Utilities Student Loans Other Loans Other Total: $ Total: $ Yes. All my total expenses are within $ of my total monthly gross income. Continue to Question 10. No. You do not qualify for an Economic Hardship Deferment. You may still qualify for forbearance. Continue to Question 7. 2 P a g e

3 7 I am requesting forbearance because my Federal Student loan payments are equal to or greater than 20% of my total monthly income. Yes. My Title IV loan payments have been equal to or greater than 20% of my monthly gross income since / /. Send copy of your last two (2) pay stub and evidence of any other income along with evidence of your title IV Federal education loan debt, including the bill or payment stub from the most recent monthly payment, beginning loan balance(s) and repayment term(s) (e.g., disclosure statements or current repayment schedules). Continue to Question 10. No. I am requesting forbearance for other acceptable reasons. I will attach a letter explaining my case. Send documents requested from questions 6 & 7, along with any other documentation to support your request. Continue to Question I am currently unable to make scheduled payments due to Poor Health (temporarily-totally disabled). *Question 8 must be completed by your physician* Patient s Name: Relationship to Patient: 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: 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 / / / / If yes, will patient be able to resume any work Yes No Yes No Physician Name Physician License Number Address City State Zip code Phone Number Fax Number Attending Physician Signature Date Continue to Question P a g e

4 Place Agency Seal or Stamp Here (Notary seal not acceptable) 9 If you are unemployed or seeking full-time employment, check and complete the following. I have been unemployed or working under 30 hours a week and have registered with the following public or private employment agency. Agency seal/stamp or letterhead required. If registered with an online agency, attach online application history. Name of Employment Agency Telephone number Agency Address (City, State, Zip) I became unemployed on / /. Attach proof of unemployment benefits, your Explanation of Benefits, from your State Agency. I have been unemployed or working under 30 hours a week. In the last six months, I have made attempts to secure full time employment at the following firm. Complete all the information requested. 1. Name of Firm Address Telephone Number Continue to Question 10. Contact Person (Name & Title) 10 I understand that: (1) I am required to continue making payments until my request has been approved. (2) This request will not be granted, unless all applicable sections of this form are completed and requested documents are submitted; (3) I may be granted a forbearance of loans that are not eligible for deferment. (4) All final decision regarding my deferment/forbearance eligibility will be made in accordance with applicable Federal Regulations. I certify that: (1) The information provided above is true and correct; (2) I will provide additional documentation, as required, to the Student Loan Office or ECSI to support my continued deferment/forbearance status; (3) I will notify My Student Loan Office or ECSI Immediately when the condition(s) that qualified me for this deferment/forbearance ends; And (4) I have read, understand, and meet the terms and conditions of the deferment/forbearance for which I have applied. ***Forbearance is granted for a period of up to one year at a time with a maximum term of three years. Interest continues to accrue during this forbearance. Interest must be paid in full at the end of each forbearance period. Further forbearance requests will not be granted if accrued interest has not been paid.*** Please continue to page 5. 4 P a g e

5 If approved for loan forbearance, I understand that interest will continue to accrue monthly, and I wish to pay this interest; (please select one) at the end of the approved forbearance. monthly as it accrues. *Please provide an address where you will be notified, if your request is If an address is not provided, you will be responsible for checking your account status online at Signature Date Mail this form and supporting documents to: The Ohio State University (59), c/o Heartland ECSI, P.O. Box 1278, Wexford, PA For Office Use Only: Economic Hardship Approved: Unemployment Approved: Yes No If yes, time period approved for: Authorizing Yes No If yes, time period approved for: Authorizing Forbearance Approved: Yes No If yes, time period approved for: Authorizing 5 P a g e