Western Illinois University Federal Perkins Loans Disability Cancellation Form

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Western Illinois University
Federal Perkins Loans
Disability Cancellation Form
The following information must be provided before a determination can be made that you are permanently
and totally disabled. Permanent and totally disabled is defined as the inability to work and earn money
because of a medically determined impairment, if that impairment is expected to continue for an indefinite
period or to result in death.
CONSENT FOR RELEASE OF INFORMATION
I hereby authorize any physicians, hospitals, or other institutions having records pertaining to my disability
to make available information from such records to Western Illinois University.
Signature of Perkins Borrower or His Representative
Date
MEDICAL INFORMATION
Nature and Extent of Disability
Date Disability Began
Cause of Disability
Present Condition
Prognosis
Anticipated Length of Total Disability
Remarks
Doctor’s Signature
Name of Doctor (please type or print)
Address
Date
Return form to:
Western Illinois University
Billing & Receivables
1 University Circle
Macomb IL 61455
Phone 309.298.1295 ~ Fax 309.298.2032
Phone #
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