Download NCSEAA Loan Program Forms

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Application for Proposed Practice Location
This form should be completed by HSM, BGMSL, BGDSL, and OSL borrowers who plan to seek loan forgiveness by practicing full-time as a physician, dentist, optometrist, pharmacist, physician assistant, or chiropractor in a qualified position in North Carolina.

Financial Statement (All scholarship-loan programs)
This form is used to request a temporary payment reduction due to financial difficulty. A borrower must complete the form in its entirety and provide documentation of all income and expenses for a one-month period. Reduced payments may be approved for periods not to exceed six months. At the end of the six-month period, if the borrower's status has not improved, an account may be reviewed for additional reduced payments.

Medical Deferment (All scholarship-loan programs)
This form is completed when a medical condition makes it temporarily impossible for a borrower to continue service or cash repayment of a scholarship-loan. A deferment is good for up to one year per occurrence.

Permanent Disability Form (All scholarship loan programs)
This form is to be completed when a physical or mental disability, in the opinion of a medical doctor, makes it impossible for a borrower to work and earn money and therefore, complete the service obligation of the loan. This form is only used when a borrower will not be able to return to the work force in any productive capacity.

Residency/Postgraduate Training Deferment (HSM, BGMSL, BGDSL, and OSL scholarship-loan programs)
This form should be completed by borrowers who are required to complete a residency, internship, fellowship, or other postgraduate training program as a requirement for licensure to practice in their profession.

Postponement Form (All scholarship-loan programs)
This form should be completed by borrowers who wish to temporarily defer or postpone service or cash repayment of his/her scholarship-loan in accordance with the deferments permitted by a program's Rules and Regulations.

Repayment Agreement (MNSP, NESLP, NSP)
This form is completed when a recipient decides not to seek service forgiveness of their loan obligation and will pay any remaining loan balance through cash.

Repayment Agreement (PFP)
This form is completed when a Principal Fellow decides to forgo the service forgiveness repayment option and who will repay the remaining loan obligation through cash.

Service Cancellation (HSM)
This form should be completed by all HSM borrowers except physicians, dentists, optometrists, pharmacists, physician assistants, and chiropractors. Physicians, dentists, optometrists, pharmacists, physician assistants, and chiropractors must complete an Application for Proposed Practice Location form

Service Cancellation (MNSP, NESLP, NSP, NET)
This form is completed by the borrower and his/her employer upon employment in a North Carolina facility that may qualify for service cancellation or forgiveness of the scholarship loan.

Service Cancellation (PFP)
This form is completed by the student and his/her employer upon employment in a public school district in North Carolina that may qualify the recipient for service forgiveness.

Service Cancellation (PTSL, TASL, PEC, FTNC, MTSLP)
This form is completed by the student and his/her employer upon employment in a public school in North Carolina that may qualify the recipient for service forgiveness.

Student Data Sheet (All scholarship-loan programs)
This form is completed when a borrower completes his/her program of study. It is kept on file at the Authority to ensure contact between a borrower and the SEAA is maintained throughout the life of the scholarship loan.

Verification of Student Enrollment (MNSP, NESLP, NSP)
This form is completed in conjunction with the postponement form for the student who wishes to postponement the repayment of loan proceeds while seeking additional education. This form must be completed by the school in which the student is enrolled.