FOR OFFICE USE ONLY
Application Decision
Delinquent Account
STL Delinquency
Approved
Denied
Yes
No
Yes
No
Loan Amount
Service Charge Amount
Repayment Date
$
$
Staff Initials
Date
E
P
Notes:
Rev: 2011-08-15 SHORT_TERM_LOAN_APP Page 1 of 2
S
TUDENT
F
INANCIAL
A
SSISTANCE
Emergency Short-Term Loan Application
Academic Year
If you need assistance with completing this form, please call our office at 480-965-3355 or visit one of our office locations
listed at students.asu.edu/contact/financialaid.
S
ECTION
A:
I
DENTIFYING
I
NFORMATION
(M
UST BE COMPLETED BY THE STUDENT
.
P
LEASE PRINT CLEARLY
.)
Last Name First Name Middle I. 10-Digit ASU ID 9-Digit Campus ID
Local Street Address
City
State
Zip Code
Daytime Phone Number
INSTRUCTIONS
YOU MUST COMPLETE Section B, C, D and E below in black or blue ink. You must also meet the following eligibility requirements:
1.
have current semester tuition/fees paid at ASU,
2. be enrolled at least half-time (6 hours for undergraduates and 5 hours for graduates) or on a Consortium Agreement,
3. be admitted to a degree seeking or certificate program,
4. must not be an Online ASU student as Online ASU students are not eligible for emergency short-term loans,
5. have a verifiable source of repayment, such as:
• expected financial aid for the current semester,
• employment (must attach a letter from employer on company letterhead),
• co-signer (this form must be notarized and a letter from employer on company letterhead must be attached).
SHORT TERM LOAN CONDITIONS
• $500 maximum per semester
• $15 service charge
• Payment due within 30 days or at the end of the current semester, whichever comes first. All short term loans must be repaid by
the end of the semester.
Note: if using financial aid as a source of repayment, it is the borrower’s responsibility to confirm that the amount of the short term
loan has been reduced from the financial aid refund.
AVAILABILITY OF FUNDS
If you apply before 2:30 PM, you can pick up your loan check at the Student Accounts Office after 10AM the next business day; otherwise, it
will take two business days. Money will be disbursed in the Student Accounts Office. To see if funds are available for disbursement, check My
ASU (my.asu.edu/myfinances) before going to the Student Accounts Office.
RETURN THIS FORM TO:
Student Financial Assistance, P.O. Box 870412, Tempe, AZ 85287-0412, unless otherwise instructed by a financial
aid staff member. FedEx and UPS customers must send to: Student Services Building #203, Forest & Gammage Parkway, Tempe, AZ 85287.
S
ECTION
B:
A
PPLICATION
I
NFORMATION
(P
LEASE PRINT CLEARLY
.)
Requested Loan Amount
Social Security Number
Birth Date
Driver’s License No. & State
$
Repayment Source
Employment
Expected Financial Aid
Other:
Permanent Street Address
City
State
Zip Code
Phone Number
Name of Employer
Position
How Long Employed
Employer Street Address
City
State
Zip Code
Employer Phone Number
Name of Co-Signer or Parent (if dependent)
Co-Signer or Parent Street Address
City
State
Zip Code
Phone Number
Co-Signer’s Social Security Number
Co-Signer’s Employer
Last Name
First Name
Middle I.
10-Digit ASU ID
9-Digit Campus ID
Rev: 2011-08-15 SHORT_TERM_LOAN_APP Page 2 of 2
S
ECTION
C:
F
INANCIAL
I
NFORMATION
(P
LEASE PRINT CLEARLY
.)
Your Monthly Income
Amount Per Month
Expected financial aid
$
Work income
$
Other, list sources:
$
Total Monthly Income $
Your Monthly Expenses
Amount Per Month
Rent/mortgage
$
Food
$
Utilities
$
Auto loan
$
Credit cards
$
Total Monthly Expenses $
S
ECTION
D:
P
ERSONAL
S
TATEMENT
(M
UST BE COMPLETED BY THE STUDENT
.
P
LEASE PRINT CLEARLY
.)
Purpose of this Loan (defined as totally unexpected and unplanned situation beyond the student’s control)
SECTION E: CERTIFICATION AND SIGNATURE (MUST BE COMPLETED BY THE STUDENT.)
Certification: I hereby certify of all the above information is true and correct to the best of my knowledge. I further understand that any false information
given on this application is grounds for denial of the loan. By my signature I understand that I must repay Arizona State University, the sum of the Loan plus
Service Charge, according to the terms of my application.
Applicant’s Signature
Date form was signed
Co-Signer’s Signature (Must be notarized.)
Date form was signed
Notary Public Signature
______________________________________________
Notary Public
