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Deral Perkins Loan Program WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document is subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097. SECTION 1: BORROWER IDENTIFICATION Please enter or correct the following information. Check this box if any of your information has changed. SSN Name Address State City Zip Code Telephone - Primary Telephone - Alternate Email.

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