Lehman College Office of Financial Aid REQUEST FOR GRADUATE PLUS DIRECT LOAN Please fill out neatly in blue or black ink only 3/17 Student’s Information: Last Name: ___________________________ First Name: ________________________________ Middle Initial: ______ SSN: ______-____-_______ EMPL#__________________ DOB: _______/_________/__________ Permanent Street Address including Apartment Street: ______________________________ Apt:________City:_______________ State:____________Zip:__________ Local Mailing Address (if Different from Permanent Address): Street: ______________________________ Apt:________City:_______________ State:____________Zip:__________ Phone #: (_____) _____-_____ E-Mail:____________________________________________ Loan Request: (MUST BE REGISTERED FOR A MINUMUM 6 CREDITS PER SEMESTER IN APPROVED DEGREE) SUMMER 2017 FALL 2017 SPRING 2018 # of GRAD Credits_____ # of GRAD Credits_____ # of GRAD Credits_____ Total Summer Loan Requested: Total Fall/Spring Loan Amount Requested $_________________ $___________________ __________________________________________________________________________________________ It is strongly suggested that you maximize your Unsubsidized loan eligibility before applying for a PLUS loan. You must complete GRADUATE online Entrance Counseling at www.studentloans.gov before your loan can be disbursed. __________________________________________________________________________________________ Borrower’s Certification: My signature below certifies that I am aware I must be making Satisfactory Academic Progress and meet all other Federal financial aid eligibility requirements in order to receive the Federal Direct Stafford Loan I am applying for. I must complete and sign a Master Promissory Note, if I am required to do so. Further, I understand that my eligibility for Federal Direct Loans will be determined in accordance with Federal Law. *In addition, my signature below authorizes Lehman College and/or the US Dept. of Education to conduct a credit check to determine my eligibility for a PLUS loan. (see reverse for important disclosure information) Applicant’s Signature: _______ _________________________________________________________________________Date_________ Intake Counselor’s Signature __________________________________________________________________________Date_________ *PRIVACY ACT NOTICE The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authority for collecting the requested information from and about you is §451 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the William D. Ford Federal Direct Loan (Direct Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate. The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the Direct Loan Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. We also use your SSN as an account identifier and to permit you to access your account information electronically. The information in your file may be disclosed, on a case-by-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions to efficiently submit student enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies. In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualified researchers under Privacy Act safeguards.