2016-2017 BANKRUPTCY STATUS FORM
STUDENT INFORMATION
Please complete this verification form and provide copies of all requested paperwork within 15 days of receipt to Governors
State University. Incomplete paperwork will not be accepted, thereby delaying the processing of your financial aid
award.
Student Name: _________________________________________________
Please Print
Last
First
GSU ID #____________________
Last 4 digits of SS#:__________________
Permanent Home Address: ___________________________________________________________________________________________________________ ______
City
State
Zip Code
Student’s Date of Birth: ____________________________Home Phone #: __________________________________Cell #: ______________________________
Email Address: ______________________________________________________ Loan Servicer(s)_____________________________________________________
WHAT YOU SHOULD DO:
The National Student Loan Data System (NSLDS) has notified our office that you are currently in active bankruptcy. You may
access your records by going to www.nslds.ed.gov and use your FSA ID to log into the website.
To determine eligibility for federal student aid we need to confirm your loan status prior to your bankruptcy, as well as
confirm that your loan(s) were not discharged or are dischargeable in your active bankruptcy.
Please sign this form acknowledging that you are in active bankruptcy and that your loans are not discharged or dischargeable.
Once we receive your form, we will determine your Financial Aid eligibility. If further documentation is needed, you will be
contacted through GSU e-mail.
CERTIFICATION AND SIGNATURES
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. The student
must sign and date this worksheet.
__________________________________________________________________________________
Student’s Signature
Date
WARNING: If you purposely give false or
misleading information on this worksheet, you
may be fined, be sentenced to jail, or both.
CRI CODE: FAC16BKY