Wesleyan University Financial Aid
Office
Annual Mellon MMUF Program
Loan Repayment Request Form
I.
Personal Information
Name
_________________________ Soc.
Sec. No. ________________ Class
______
Graduate
School Address
Permanent/Home Address (if different)
__________________________________
____________________________________
__________________________________
____________________________________
__________________________________
____________________________________
Phone
No. (____)____________________
Phone No.( ___)______________________
II.
Loan Information
The following information
must be submitted before educational loans can be repaid.
A.
Indicate loan to be repaid with this request:
____Federal
Stafford
____Federal
Perkins
____Wesleyan
Long-Term Loan
____Wesleyan Student Loan
____Other________________________________________________________
B.
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:
D.
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_________
Page 2
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 Schools
Registrars 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
Butterfield B
Middletown, CT
06459-0260
(860) 685-3084
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