Mellon Mays Undergraduate Fellowship Program

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.

 

  1. Indicate loan to be repaid with this request:

____Federal Stafford                                      ____Federal Perkins

____Wesleyan Long-Term Loan                    ____Wesleyan Student Loan

____Other________________________________________________________

 

  1. Please list the name and address of your lending agency and your account #

Lending agency:

_________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________

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:

 

  1. 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_________

 

 

III.       Checklist

 

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.

 

Signature_____________________________________       Date____________________

 

Please return to:          Renee Johnson-Thornton

                                    Mellon Mays Undergraduate Fellowship Program

                                    Office of the Dean for Diversity and Student Engagement

                                    North College Room 122

                                    Middletown, CT 06459-0260

(E-mail) rjohnson01@wesleyan.edu                      (FAX) 860-6853761  

Updated 8/22/13