Annual Mellon Loan Repayment Request Form - Mellon Mays Undergraduate Fellowship Program

I. Personal Information

Name

First

Last

Student ID Number

Graduate School Email Address

Name of Graduate Program

to Graduate Loan

Graduate School Address

Address Line 1

Address Line 2

City

State

Zip Code

Permanent/Home Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Phone No.

Cell No.

II. Loan Information

The following information must be submitted before educational loans can be repaid.

Indicate loan to be repaid with this request:

Federal Stafford
Federal Perkins
Institutional Student Loan

Please list the name and address of your lending agency and your account #

Lending Agency Name

Lending Agency address to which checks should be mailed

Address Line 1

Address Line 2

City

State

Zip Code

Account Number

Student's Name as is appears on the account

First

Middle

Last

Remaining Balance

Please complete the information below

Graduate Program Year

Loan Forgiveness Received So Far ( select all that apply )

For Other, put the loan amounts not equal to standard payments

Loan Forgiveness Request ( select all that apply )

For Other, put the loan amounts not equal to standard payments

REQUIRED FILES TO UPLOAD:

Unofficial Transcript

Click or drag a file to this area to upload.

Institutional Verification from Graduate School Registrar

Click or drag a file to this area to upload.

Download the form at https://pomona.box.com/s/uotq2xbwq2dcmrhhiio1sh28lr23ejy9

Loan Provider Statement

Click or drag a file to this area to upload.

Upload the most recent statement from your loan provider.

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. All of the above information is correct to the best of my knowledge.

Signature

Clear Signature

Date / Time