Direct Loan for Graduate Students (Plus)

FAIRMONT STATE UNIVERSITY

DIRECT LOAN FOR GRADUATE STUDENTS (PLUS)

2014-2015 DATA SHEET

This form is only to be completed by a graduate student who wishes to borrow through the Federal Direct Plus Loan Program. Please PRINT clearly with blue or black ink.

Student Name:______

Last First MI

Student Social Security #:______

Loan Amount Requested: $______

Permanent Home Address______

Street Address

______

City State Zip Code

Date of Birth: ______Telephone Number: ______

Are you a citizen?

______YES ______NO, but I am an eligible non-citizen. Alien#: ______

Driver’s License #: ______State ______

Are you currently in default on an educational loan or do you owe a refund on a federal student grant? ______YES ______NO

Loan Period: Fall /Spring ______Fall Only ______Spring Only ______Summer ______

I authorize the Secretary of the U.S. Department of Education to investigate my credit record and report information concerning my credit to the proper persons and organizations.

ACCOUNTS RECEIVABLE ACKNOWLEDGEMENT: By signing this application I acknowledge that I am responsible for any unpaid balance on my account. If I do not pay my unpaid balance I understand that my account will be turned over to a collection agency after 60 (sixty) days delinquent. Collection costs of 30 (thirty) percent will be added to my account when sent for collection.

Student Signature: ______Date: ______

RETURN FORM TO: FAIRMONT STATE UNIVERSITY

FINANCIAL AID AND SCHOLARSHIPS

1201 LOCUST AVNEUE

FAIRMONT, WV 26554

FAX: (304)367-4789

All loan proceeds are released in two disbursements and will be applied to outstanding balances owed to FAIRMONT STATE. Any remaining proceeds will be disbursed in a check made payable to the student and mailed to his/her permanent address. You have the right to cancel all or a portion of this loan within 30 days of disbursement by submitting a written request to the FINANCIAL AID AND SCHOLARSHIP OFFICE.