Deferment of Repayment Request

Part I - TO BE COMPLETED BY THE BORROWER

Name: ____________________________________   Account Number: _________________

_______________________________________________
Address

_______________________________________________        ________________
City                                                 State         Zip Code               Phone Number


This is to certify that I have been (Check One Item)
___ At least a half-time student  ___ Officer in public health service 
___ Active duty in armed forces ___ Peace Corps
___ Vista  ___ Internship
___ Volunteer in tax-exempt organization
  From (Month/Year) _______ To (Month/Year) ______

I claim exemption from payment of principal and accrual of interest on my loan during the period indicated above. I agree to notify the lending institution immediately upon termination of my claimed status. I understand deferments are not given beyond the date of certification. I agree to submit a certified deferment form at the end of Spring and Fall semesters of each year I attend school at least on a half-time basis or every six months for other types of deferments.

    ___ Check here if you expect to be eligible for deferment again and if so through
           what period: Month ________ Year ________

__________________________________________                  _____________
Signature of Borrower                                                                   Date 


PART II - TO BE COMPLETED BY CERTIFYING AUTHORITY

I certify that the information stated in PART I above is true and correct.

__________________________________________                  ______________
Signature of Certifying Official                                                     Date

___________________________________                                Official Seal or Stamp
Name of Organization                                                                    (If none, include signed
                                                                                                       letter of certification)
___________________________________

___________________________________
Address of Organization

Telephone Number: ___________________
Title IV Institution Code for Student Deferment: __________________

Return the certified form to the lending institution:      University of Maryland
                                                                                     Office of the Bursar
Form Sent: __________                                               College Park, MD. 20742-5151
Form Due: __________                                               (301) 405-9030 FAX (301) 314-9098