Financial Arrangements Form Completed – Fill Out and Use This PDF

PART I – MUST BE COMPLETED BY BORROWER

FINANCIAL STATEMENT

1. Marital Status: (check one)

2. Dependents:

Name

Relationship

Age

Single

Widow(er)

Married

Divorced or Separated

3. Monthly Income:

(Please provide written documentation supporting reported income)

Gross Monthly Income

$

Deductions

$(

)

Net Monthly Income

$

Public Assistance and type:

$

Support Income (if separated or divorced)

$

Other Income and type:

$

TOTAL MONTHLY INCOME

$

List all outstanding student loans by name/type and Lending Institution. Provide supporting documentation for all educational loans not owed to the Lending Institution to which you are submitting this application. Include the original total loan amounts, outstanding loan balances and monthly payment amounts. If a loan is currently deferred, provide the monthly payment amount as if it were not in deferment.

Loan Name/Type Lending Institution

Original Loan Amt.

Balance Outstanding

Monthly Payments

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Monthly Expenses:

Balance Outstanding

Monthly Payments

Mortgage/Rent

$

$

Car Expenses

Loan

$

$

Gas, Oil, Insurance

$

$

Bank Loans (list type):

$

$

$

$

$

$

Other Outstanding Loans (personal)

$

$

Credit Cards:

$

$

$

$

$

$

Medical

$

$

Utilities

$

Telephone

$

Insurance (Life, Health, Home)

$

Food

$

Monthly Support Payments (if separated or divorced)

$

Other Expenses:

$

$

TOTAL MONTHLY EXPENSES

$

NET TOTAL (Monthly Income Minus Total Monthly Expense)

$

Assets:

Savings Account Balance (Bank Name)

$

Checking Account Balance (Bank Name)

$

FAF-105 (11/06)

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PART II – MUST BE COMPETED BY BORROWER

4.Employment Information: Provide information for current or most recent employer. Employer Name:

Employer Address:

City

State

Zip

Employer Phone:

(

)

Full-time:

Part-time:

Date of hire:

Date last worked:

Number of hours worked per week:

Hourly Rate:

Salary:

Check all that apply

I am employed and experiencing financial difficulty.

I am seeking and unable to secure full-time employment. (Provide list of companies with whom you have interviewed.)

I have registered with an employment agency. (Provide registration documentation)

I am receiving unemployment benefits. (Provide official documentation of this benefit)

I am not eligible to receive unemployment benefits. (Provide supporting documentation of ineligibility)

I have never been employed.

5.Other situations. Check all that apply: (Supporting documentation may include: check stubs, employer stubs, benefit verification on official letterhead, copy of Federal tax return)

I have been granted economic hardship for a Federal Direct Student Loan or a Federal Family Education Loan.

(indicate dates of hardship period:

) Attach official documentation of this benefit.

I am receiving payment under federal or state public assistance. (AFDC, SDI, SSI, Food Stamps, State-sponsored General Assistance, etc.) Attach official supporting documentation.

6.Please describe the circumstances of your present financial situation. (Attach a separate sheet of paper if additional space is needed)

7. I am able to pay the interest due throughout any hardship or forbearance benefit granted, please bill me.

I am unable to pay the interest due throughout any hardship or forbearance benefit granted. I will pay the interest after my hardship deferment or forbearance has ended. Federal Perkins, HPSL, NSL and LDS loans accrue interest that will be billed in a lump sum at the end of the hardship deferment or forbearance.

8. MONTHLY PAYMENT ARRANGEMENT: If you feel you can make payments toward your account(s), complete this section.

Based on my financial situation, I am proposing to make payments in the amount of $. Pending approval,

if payment is not made, I understand that the Lending Institution may terminate this agreement if consecutive payments are not received. Past-due notices will be sent if payment is not received by the fifteenth of each month.

FAF-105 (11/06)

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PART III – MUST BE COMPLETED BY BORROWER

Borrower is responsible to advise UAS of current address.					***Your 14 digit account number ensures proper handling of this form***
NAME OF BORROWER:					ACCOUNT NUMBER(S):
					NAME OF LENDING INSTITUTION:
PERMANENT ADDRESS:		Check if new address
					(College/University from which loan originated)
					SOCIAL SECURITY NUMBER:
E-MAIL ADDRESS					WORK PHONE NUMBER	(	)
HOME PHONE NUMBER (		)			CELL PHONE NUMBER	(	)

I understand that all information and supporting documents submitted will be held in strictest confidence and will not be subject to dissemination outside the requirements of the Lending Institution. I further understand that this arrangement will consist of reduced or deferred payments, as determined by the Lending Institution based on my financial situation. It may be necessary to make accelerated payments at the expiration of this arrangement to repay the loan within the maximum repayment period.

I certify that all statements made are true and correct. I also certify that I will immediately notify the Lending Institution of any change in my employment status or significant change in my financial situation. I authorize a representative of the Lending Institution to obtain pertinent information from applicable parties for verification purposes.

Borrower Signature	Date
(Failure to sign will result in form being returned.)

Please forward completed form to:

PART IV – TO BE COMPLETED BY THE LENDING INSTITUTION/UAS –The Lending Institution should detach and send this page to UAS for processing. The Lending Institution official must send borrower verification of benefits granted or benefit denial.

FAF-105 (11/06)

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