Application and Promissory Note for Federal PLUS LOAN
OMB NO. 1845-0009 Form Approved Exp. Date 07/31/2001
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form is subject to penalties which may include fines or imprisonment under the United States Criminal Code and 20 U.S.C 1097.		 Guarantor or Program Identification
Borrower Section(To be completed by the parent.)                                 Please print neatly or type. Read the instructions carefully.
1.Last Name                                  First Name                                                           MI
   		2.Social Security Number
         
3. Permanent Street Address(if P.O.Box, see instructions.) 4.TelephoneNumber
 		5. Loan Period(Month/Year)
FromTo
City                                           State                   Zip Code
6.Driver'sLicenseNumber
 7. Date of Birth(Month/Day/Year)
8. Lender Name                    City                       State            Zip Code

9.LenderCode,ifknown

 

10. Request Loan Amount
$
11.U.S.Citizenship Status(Check one and list ID #  if applicable.)                a.   Citizen/National            b.   Eligible Non-citizen Alien ID #
12. a. State of Legal Residence   b. Since(Month/Year)

 

13.Employer(Name,City,State)             Telephone Number
14. Are you currently in default on a federal education loan, or do you owe a refund on a federal student grant? If yes, carefully read instructions and attach required documentation. a. Yes b. No
15. If the school your dependent is attending participates in electronic funds transfer(EFT), do you authorize the school to transfer the loan proceeds received by EFT to your dependent's student account? a. Yes b. No
16. Do you have an outstanding Federal Stafford, Supplemental Loan for students, Parent PLUS, or Consolidation Loan which was disbursed before July 1, 1993?
if you checked "yes", do you want to postpone (defer) payment of the principal of this loan based on the student's in-school status?
if you checked "yes" to Box(a) and  (c), do you want the interest that accrues on this loan deferred and capitalized? if no, you will be required to pay the interest.		 a. Yes

c. Yes

e. Yes

b. No

d. No

f. Yes
17. References: You must provide two separate references with different U.S. addresses. Both references must be completed fully
Name                                         1.                        2. 
Permanent Address                                                 
City, State, Zip Code                                                
Area Code/Telephone                                              
Promissory Note
Promise to pay: I promise to pay to the lender, or a subsequent holder of this Promissory Note, all sums disbursed(hereafter,"loan" or "loans") under the terms of this Note, plus interest and other fees which may become due as provided in this Note. If I fail to make payments on this Note when due, I will also pay reasonable collection costs, including attomey's fees, court and collection fees. I understand I may cancel or reduce the size of any loan by refusing to accept any disbursement that is issued. I understand that this is a Promissory Note. I will not sign this Note before reading it, including the writing on the reverse side, even if otherwise advised. I am entitled to an exact copy of this Promissory Note and the Browser's Rights and Responsibilities. My signature certifies I have read, understand, and agree to the terms and conditions of this Application and Promissory Note, including  the Browser Certification and Authorization, and the accompanying Borrower's Rights and Responsibilities statement.
THIS IS A LOAN THAT MUST BE REPAID.
18. Borrower's Signature  Today's Date(Month/Day/Year)
Student Section (To be completed by the student.)                    Please print neatly or type. Read the instructions carefully
19. Last Name                                 First Name                     MI
  20.Social Security Number
 21. Date of Birth (Month/Day/Year)
22. U.S. Citizenship Status(Check one and list ID number if applicable.)               a.Citizen/National          b. Eligible Non-citizen Alien ID #
23. Are you currently in default on a federal education loan, or do you owe a refund on a federal student grant? If yes, carefully read instructions and attach required documentation                                                       a. Yes               b. No
24. MY signature certifies that i have read, understand and agree to the conditions in the Student Certification and Authorization printed on the reverse of this Application and Promissory Note.
     Student's Signature              Today's Date (Month/Day/Year)
School Section (To be completed by an autorized school official.)
25. School Name
 31. School Code/Branch
 		36. Telephone Number
26. Street Address
          City                                         State                       Zip Code                                   		 32. Cost of Attendance
$ .00		 37. Recommended Disbursement Date(s) (Month/Day/Year)


          1st                    2nd
33. Estimated Financial Aid
$.00
27.Loan Period (Month/Day/Year)
FromTo		 28. Grade Level
 34Certified Loan Amount
$.00
          3rd                   4th
29. Enrollment Status(Check one)
Full Time                        At Least Half Time		 35. Signature of Authorized School Official/Date(See School Certification box on the reverse side.)

Print or Type Name and Title             Check box if electronically
                                                          transmitted to guarantor.
30. Anticipated Completion(Graduation) Date(Month/Day/Year)
Lender Section(To be completed by an authorized lending official.)
38. Lender Name
 39.Lender Code/Branch
 40. Telephone Number
 41. Amount Approved
Street Address 42. Signature of Authorized Lending official

Print Type Name and Title    Date		 43. Lender Use Only
City                                                       State                              Zip Code