Form HRSA-512 Federal Health Education Assistance Loan Program

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN PROGRAM

(42 U.S.C. 292-292o)

HOLDER’S REPORT ON HEALTH EDUCATION ASSISTANCE LOANS (HEAL)

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0043. Public reporting burden for officials for this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 11-05, Rockville, Maryland 20857.

INSTRUCTIONS

Complete all sections of the form which are applicable and return to:

U.S. Department of Health and Human Services Health Resources and Services Administration Division of Health Careers Diversity & Development, Room 8-37

5600 Fishers Lane

Rockville, MD 20857

GENERAL INSTRUCTIONS

The holder’s report on HEAL activities is due quarterly. The report must be completed and returned within 30 calendar days following the end of the reporting period. Failure to submit the report on time may result in the suspension of a holder from holding HEAL loans and or suspension of receiving payment of their insurance claims. (42 CFR 60.42 and 60.43)

NAME AND ADDRESS OF HOLDER INSTITUTION

Enter the name and address, including zip code, of your financial institution.

HOLDER IDENTIFICATION NUMBER

Enter the six-digit number assigned by the HEAL Branch to identify your institution. Holders having more than one identification number with outstanding HEAL loan portfolios must complete multiple reports.

OTHER PERTINENT POINTS

For each section enter the sum of all sub-sections on the total line for the section.

For Number of Borrowers, enter the number of unduplicated borrowers as of the end of the reporting period.

For Number of loans, enter the number of loans as of the end of the reporting period.

Dollar amounts should include principal plus accrued interest as of the end of the reporting period. All amounts should be reported in whole dollars: e.g., $10,108 NOT $10,107.50

All requests for assistance or for additional information regarding the report should be directed to the HEAL Branch at (301) 443-1540.

PLEASE READ INSTRUCTIONS BEFORE
COMPLETING THESE SECTIONS

SECTION I. LOANS IN STUDENT STATUS AND GRACE PERIOD

I. STUDENT STATUS - Enter the total number of borrowers, loans in student status and the total dollar amount of principal and interest outstanding for those borrowers. Do NOT include in Student Status borrowers who are in Internship or Residency Status.

2. GRACE PERIOD - Enter the total number of borrowers, loans and the total dollar amount of principal and interest outstanding for those borrowers in their grace period.

SECTION II. LOANS CURRENTLY IN REPAYMENT STATUS AND NOT PAST DUE

SECTION II reflects those total dollar amounts and number of loans to borrowers who are beyond student status and who are not past due on their payment; or who are in an eligible deferred status (including those in internship or residency); or who are in forbearance status.

l. ON SCHEDULE WITH PAYMENTS - Enter the total number of borrowers, loans and the total dollar amount of loans (principal and interest) for those borrowers who are making payments in accordance with their repayment schedule.

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HRSA-512 (INSTRUCTIONS)

Rev. 06/ 06

. DEFERRED STATUS (Including Internship and Residency). - Enter the total number of borrowers, loans and the total dollar amount (principal and interest) for those borrowers who are in any deferrable status as defined in sections 60.11 and 60.12 of the HEAL regulations including those in an internship or residency.

3. FORBEARANCE STATUS - Enter the total number of borrowers, loans and the total dollar amount (principal and interest) for those borrowers in forbearance as of the last day of the reporting period (section 60.37 of the HEAL regulations).

SECTION III. LOANS PAST DUE BY LENGTH OF TIME AS OF THE END OF THE REPORTING PERIOD.

This section shows the distribution of HEAL borrowers, loans and unpaid balance on HEAL loans (principal and interest) past due by length of time and discipline.

Enter the total number of borrowers, loans and the unpaid balance of their loans according to the number of days their loans are past due. Entries for Number of Borrowers are unduplicated numbers of borrowers; i.e., a borrower whose payment is past due 91 days would be included only in the 91-to-150-day category. This same relationship also applies to the dollar and number of loans entries.

SECTION IV. AMOUNT REPAID ON LOANS

Reporting of this information became effective with the reporting period, July 1, 1989 through September 30, 1989, and for all subsequent quarterly periods.

1. AMOUNT PAID ON HEAL LOANS OUTSTANDING - Enter the number of borrowers, amount, and number of HEAL loans (principal and interest) repaid for the HEAL loans currently outstanding (as reflected in Section V of this report). For example, if the total amount of the borrower's loan was $15,000 (principal and interest) as of the effective date for completing this section, and if the borrower has repaid $5,000 of that amount, then the $10,000 remaining outstanding will be reflected in Section V, and the $5,000 repaid by the borrower should be reported in Section IV(1).¹

2. HEAL LOANS PAID IN FULL - Enter the number of borrowers, total cumulative dollar amount and number of HEAL loans paid in full by borrowers. (Enter total principal and interest repaid). The amount and number of these loans were previously reported in Sections I, II, or III and will now be reflected in Section IV. (Claims paid by HHS due to default, death, disability, or bankruptcy are NOT to be included here).

SECTION V. TOTAL HEAL LOANS OUTSTANDING

(Sum of Sections I, II, and III.)

Total HEAL Loans Outstanding represents that amount of principal and interest and number for all HEAL loans currently owed to and currently held by a holder/holder. The Number of Borrowers and the Dollar Amount entered in this Section should equal the sum of the figures shown in Section l, II, and Ill.

REMINDER: Holders should maintain a copy of this report in your official holder records.

¹Example is for purposes of illustration only and does not necessarily reflect variable interest which accrues.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
Bureau of Health Professions

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN PROGRAM

(42 U.S.C. 292-292o)

FORM APPROVED

OMB NO. 0915-0043 Exp. Date:

READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM.

REPORT PERIOD

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M M D D Y Y

OLDER’S REPORT ON HEALTH EDUCATION ASSISTANCE LOANS (HEAL)

NAME AND ADDRESS OF HOLDER INSTITUTION: HOLDER’S IDENTIFICATION ____ ____ ____ ____ ____ ____			COMPLETE THIS FORM AND RETURN TO: Division of Health Careers Diversity and Development, BHPr, HRSA HEAL Program, Room 8-37 5600 Fishers Lane Rockville, Maryland 20857
STATUS OF HEAL LOANS		NUMBER OF BORROWERS		NUMBER OF LOANS		DOLLAR AMOUNT
SECTION I - LOANS IN STUDENT STATUS AND GRACE PERIOD (1) STUDENT STATUS						$
(2) GRACE PERIOD						$
TOTAL SECTION 1						$
SECTION II - LOANS CURRENTLY IN REPAYMENT STATUS AND NOT PAST DUE (1) ON SCHEDULE WITH PAYMENTS						$
(2) DEFERRED STATUS						$
(3) FORBEARANCE						$
TOTAL SECTION II						$
SECTION III - LOANS PAST DUE (1) 1 - 90 DAYS						$
(2) 91 - 150 DAYS						$
(3) OVER 150 DAYS						$
TOTAL SECTION III						$
SECTION IV - AMOUNT REPAID ON LOANS (1) AMOUNT PAID ON HEAL LOANS OUTSTANDING						$
(2) HEAL LOANS PAID IN FULL						$
TOTAL SECTION IV						$
SECTION V - TOTAL HEAL LOANS OUTSTANDING (THE SUM OF SECTIONS 1, 11, AND III)						$
SIGNATURE OF AUTHORIZED OFFICIAL	NAME AND TITLE (PRINT OR TYPE)				DATE		TELEPHONE (Include area code) ( )

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HRSA-512 (FORM)

Rev. 06/ 06

ARNING: Any person who knowingly makes a false statement of misrepresentation on this form may be subject to a fine of up to $10,000 or to imprisonment of up to five years or both under provisions of the United States Criminal Code. Such provision may include among others, 18 U.S.C. 1001.