Msa Emergency Loan Application Form

IowaStateUniversity

Office of Multicultural Student Affairs

Emergency Loan Program

Today’s Date ______

MSA Emergency Loan Application Form

MLK Emergency Loan (9996)

Student Completes Sections A, B, and C (please print)

A. STUDENT INFORMATION
Name: E-mail:

Last/first/middle initial

University ID#:
Local Address:
Local Phone:() Cell Phone: ()
Academic Year: Freshman Sophomore Junior Senior Graduate Program
Major: GPA: Term Credits:
B. LOAN REQUEST INFORMATIONAmount Requested: $
Purpose of Loan (provide copies of supporting documentation,e.g. lease if request is for rent):
Have you received your financial aid for this semester? Yes No
Have you consulted with a financial aid advisor? Yes No
Have you utilized all sources for grants and loans offered? Yes No
Do you presently owe an MSA Loan? Yes No If yes, amount $
Are you currently employed? Yes No If yes, by whom?
If not, how will you repay this loan?
C. AGREEMENT STATEMENT (please initial boxes next to the statements if you agree)
I understand that all monies issued are intended for loan purposes only and must be paid on the 20th day of the following month, otherwise due in fullon or before ______.
Should I not return to IowaStateUniversity due to graduation, transfer, withdrawal, or for any other reason, the loan will become due in full immediately.
I understand that should I need to request additional loan assistance from the MSA office during this academic year, I will be required to meet with a representative of ISU's Financial Counseling Clinic for assistance in drafting a personal financial budget.
I understand and agree to all the conditions of this transaction.
Applicant Signature: Date://

For Office Use Only: MSA rep should use ADIN and Access Plus to help verify eligibility.

D. LOAN ELIGIBILITY AND CONDITIONSPlease check to see that student is/has:
Currently enrolled at IowaStateUniversity.
Met all the criteria for an MSA Emergency Loan: attach ADIN financial summary
In good academic standing: Cum GPA .
Met with a representative at ISU Financial Aid Office.
Exhausted all financial resources offered by Financial Aid (loans, grants, etc.).
Demonstrated need by providing documentation to support loan request.
Signed a disclosure/promissory note and statement above, agreeing to repay loan by specified date.
Loan is: Approved Denied
By:
Outreach Coordinator, (print)
Multicultural Student Affairs:
(sign)
Director, Multicultural Student Affairs:
Amount: $ Agreed-Upon Follow-Up Date: //

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