Annual Mellon Loan Repayment Request Form
I. Personal Information
Name _________________________ Soc. Sec. No. ________________ Class ______
Email address ______________________________________________________________
Graduate School Address Permanent/Home Address (if different)
Phone No. (___)_________________ Cell No. (___)______________________
II. Loan Information
The following information must be submitted to the Financial Aid Office before educational loans can be repaid.
- Indicate loan to be repaid with this request:
____Federal Stafford ____Federal Perkins
____Wesleyan Long-Term Loan ____Wesleyan Student Loan
- Please list the name and address of your lending agency and your account #
Please complete the information below:
C. This is my 1st 2nd 3rd 4th (circle one) year in graduate school.
I have completed my PhD: ________
If loans have been repaid in full, complete the following:
- I am submitting official documentation from my lender indicating that I have paid
my loan(s) in full. Remit funds in my name to my:
Graduate School address___________ Permanent/Home address_________
THE FOLLOWING INFORMATION MUST BE ATTACHED TO THIS FORM:
1. Deferment Confirmation
Federal Stafford Loan borrowers must supply deferment status confirmation from their lender on official letterhead. Federal Perkins Loan borrowers should check with the Student Loan Office at Wesleyan University for deferment documentation.
2. Official Verification of Enrollment
Enrollment verification must be obtained from your Graduate School’s Registrar’s Office. The official document must verify your enrollment during the academic period for which you are requesting loan repayment (maximum one academic year).
3. Institutional Letter from Graduate School
You must ask your graduate institution to submit a letter certifying that you have satisfactorily completed your course work. This letter must be submitted at the end of each academic year and it must be specific to the academic year cited in #2. This letter does not necessarily need to accompany this form. Note: An academic transcript will NOT suffice.
STATEMENT OF UNDERSTANDING:
I agree to notify the Financial Aid Office and the Mellon Mays Undergraduate Fellowship Program of any changes in the facts reported on this form. I have reviewed the terms and conditions of the Mellon Loan Repayment Program (see Exit Interview). All of the above information is correct to the best of my knowledge.
Please return to: Camille Martin
Mellon Mays Undergraduate Fellowship Program
343 High Street Room 124
Middletown, CT 06459-0260
(E-mail) firstname.lastname@example.org (FAX) 860.685.2041