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



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


            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.




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:          Amy Bello

                                    Mellon Mays Undergraduate Fellowship Program

                                    Administrative Assistant

                                    343 High Street Room 124

                                    Middletown, CT 06459-0260


Updated 8/19/15