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.

Loan Forgiveness (FELS)
This form should be completed by all FELS borrowers.

Loan Forgiveness (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

Loan Forgiveness (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.

Loan Forgiveness (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.

Loan Forgiveness (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.

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.

Notice of Intent to Seek Loan Forgiveness (All scholarship-loan programs)
This form should be submitted to the SEAA within 90 days of graduation to indicate whether a borrower intends to repay the scholarship loan by loan forgiveness or cash repayment.

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.

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.

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.

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
This form is completed in conjunction with a postponement request form for borrowers who wish to postpone or delay service forgiveness or cash repayment of a scholarship-loan due to student enrollment. This form must be completed by the school in which the student is enrolled.