Attachment II

Emergency Tuition Loan (ETL) Program

Request for Deferred Repayment or Extension of Due Date

Students who are not financially able to pay an ETLP in full on or before the Due Date may qualify for either (a) Extension of the Due Date or (b) Deferred Repayment, but not both. Generally, students qualify for an Extension of the Due Date because of extraordinary circumstances (such as a medical emergency of their own or a family member). Written documentation may be required to substantiate the extraordinary circumstances. Deferred Repayment is available only to those students having an effective family contribution that would qualify them as Pell eligible on the Due Date of the ETL (Refer to UPPS No. 07.07.05). Mark the appropriate section below to select either (a) Extension of Due Date OR (b) Deferred Repayment.

_____ (a) Extension of Due Date

I, the undersigned, hereby request an extension of the Due Date of my Emergency Tuition Loan (ETLP) which I previously executed as a promissory note with Texas State University-San Marcos. I understand and agree that this extension modifies that note only as to Due Date and that all other terms and conditions remain in full force and effect.

____________________________________ __________________________

Student Name Date I.D. Number

___________________________________ __________________________

Current Address Current Phone #

___________________________________ __________________________

Student Signature Extended DUE DATE

______ (b) Deferred Repayment (Only for students qualifying for maximum Pell eligibility)

I, the undersigned, hereby request Deferred Repayment of my Emergency Tuition Loan (ETLP) which I previously executed as a promissory note with Texas State University-San Marcos. I understand and agree that this deferral modifies that note only as to Due Date and that all other terms and conditions remain in full force and effect. I agree that the deferred Due Date must be the earlier of (1) the first day of the ninth month after the last month in which I am enrolled at Texas State or (2) the fifth anniversary of the date on which the loan was executed.

_______________________________ _________________________

Student Name Date I.D. Number

_______________________________ _________________________

Current Address Current Phone #

_______________________________ _________________________

Student Signature Deferred DUE DATE

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APPROVAL:

____________________________________________________________________

Texas State Representative Date

Form # FA-22