2023-2024 Total & Permanent Disability Form

TPDFORM myUH ID __________

4434 University Drive, Houston, Texas 77204-2010 · Phone (713)743-1010 · Fax (713)743-9098

Welcome Center hours: Monday-Thursday, 8 a.m.-5 p.m.; Friday, 9 a.m.-5 p.m. · www.uh.edu/verification

The U.S. Department of Education has informed us that you have either: (1) indicated that you will apply for a Total and Permanent

Disability (TPD) discharge, (2) applied for a TPD discharge, (3) or have received a TPD discharge. If you receive a Federal Direct Loan or

Federal TEACH Grant, it may affect your eligibility for a discharge, or may cause your loan or grant obligation to be reinstated.

If you have applied for, or are in the process of applying for, a TPD discharge, but the application has neither been approved nor rejected,

any disbursements of a Federal Direct Loan or Federal TEACH Grant that are made may cause your application for TPD discharge to be

suspended until the disbursement is returned, or may cause your TPD application to be rejected. Contact the TPD Servicer* for specific

information on the status of your TPD application and guidance on the impact that receiving Federal Direct Loans or Federal

TEACH Grants may have on your TPD application. (*TPD Servicer: Nelnet 1-888-303-7818)

A. Student Information

_____________________________________________________________ ________________________

Last Name First Name MI myUH ID

_____________________________________________________________ ________________________

Email Address Date of Birth

B. Financial Aid Information

Please answer the questions below and provide any documentation that may be needed to complete the processing of your financial aid. We

cannot process your financial aid until we receive this information.

o you wish to apply for a Federal TEACH Grant? YES NO

Do you wish to apply for a student loan? YES** NO

*If you wish to take out a student loan, you must submit a certification letter, from a legally licensed physician, stating that your condition

has improved and that you have the ability to engage in “substantial gainful activity,” which includes:

1. C

apability of attending school,

2. Of completing a program of student, and

3. Of securing employment in order to repay the new loan

If you are applying for student loans the physician’s certification letter should be turned in with this form in order to be

processed for financial aid.

If you are requesting student loans, by signing below, you are acknowledging that the new student loan, or Federal TEACH Grant service

obligation, cannot later be discharged for any present impairment, unless the condition substantially deteriorates to the extent that the

definition of total and permanent disability is met again. Please be advised that obtaining a new student loan may reactivate any previous

loans that were discharged due to total and permanent disability.

C. Certification and Signature (blue/black ink only, no electronic signatures accepted)

By signing this form, you certify that all the information reported on it is complete and correct, and that you understand that the submission

of this form is not a guarantee of financial aid. If you are requesting student loans, your signature below certifies that you have understood

the information listed in the box above.

_________________________________ _____________

Student Signature Date

State law requires that you be informed of the following: (1) with few exceptions, you are entitled on request to be informed about the information the University collects about you by use of this form; (2) under sections 552.021 and

552.023 of the Government Code, you are entitled to receive and review the information; and (3) under section 559.004 of the Government Code, you are entitled to have the University correct information about you that is incorrect