Loan Discharge Application: September 11, 2001 Survivors

OMB No. 1845-0079 Form Approved Exp. Date 07/31/2007

LOAN DISCHARGE APPLICATION: SPOUSES AND PARENTS OF SEPTEMBER 11, 2001 VICTIMS Federal Family Education Loan Program / Federal Perkins Loan Program / William D. Ford Federal Direct Loan Program WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents will be subject to penalties which may include fines, imprisonment or both, under the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: BORROWER INFORMATION

Please enter or correct the following information.

SSN |__|__|__|-|__|__|-|__|__|__|__|

Name

Address

City, State, Zip

Telephone - Home ( )

Telephone - Other ( )

E-mail address (optional)

SECTION 2: INSTRUCTIONS FOR COMPLETING THE FORM

Carefully read the entire form, including the definitions and other information on pages 2, 3, and 4. Type or print in dark ink. If you are applying for discharge of more than one loan and your loans are held by more than one loan holder, you must submit a separate discharge application (original or copy) with any accompanying attachments to each holder. A “copy” means a photocopy of the original form that you completed. If you submit copies, you must sign each copy separately. If any of the information in Section 1 is missing or incorrect, provide the missing or correct information. Enter your name and social security number at the top of page 2 (if not preprinted). If you are applying for discharge on the basis that you are the spouse or parent of an individual who died due to injuries suffered in the September 11, 2001 terrorist attacks, you must complete Sections 3, 4 and 5 of this form and provide the documentation specified in Section 9. If you are applying for discharge on the basis that you are the spouse or parent of an individual who became permanently and totally disabled due to injuries suffered in the September 11, 2001 terrorist attacks, you must complete Sections 3, 4 and 5 of this form, and the eligible public servant or other eligible victim must complete Section 6. A physician must complete Section 7. In addition, you must provide the documentation specified in Section 9. A representative may complete Section 6 on behalf of the eligible public servant or other eligible victim if that individual is unable to do so because of his or her disability.

SECTION 3: BORROWER REQUEST FOR LOAN DISCHARGE

I meet the qualification for loan discharge checked below and request that my loan holder discharge my eligible loan(s) made under the Federal Family Education Loan (FFEL) Program, the Federal Perkins Loan (Perkins Loan) Program, and/or the William D. Ford Federal Direct Loan (Direct Loan) Program. Check one: My spouse was an eligible public servant who died due to injuries suffered in the terrorist attacks on September 11, 2001. I have provided the documentation specified in Section 9, Item A. I am the spouse of an eligible public servant who became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001. I have provided the documentation specified in Section 9, Item C, the eligible public servant has completed Section 6, and a physician has completed Section 7. My spouse was an eligible victim (other than an eligible public servant) who died due to injuries suffered in the terrorist attacks on September 11, 2001. I have provided the documentation specified in Section 9, Item B. I am the spouse of an eligible victim (other than an eligible public servant) who became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001. I have provided the documentation specified in Section 9, Item D, the eligible victim has completed Section 6, and a physician has completed Section 7. I am the eligible parent of an eligible victim who died due to injuries suffered in the terrorist attacks on September 11, 2001. I have provided the documentation specified in Section 9, Item B. I am the eligible parent of an eligible victim who became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001. I have provided the documentation specified in Section 9, Item D, the eligible victim has completed Section 6, and a physician has completed Section 7.

SECTION 4: BORROWER UNDERSTANDINGS AND CERTIFICATIONS

I understand that I may be required to provide additional documentation to establish my eligibility for loan discharge. I also understand that I must submit a separate discharge application to each holder of the loans that I want to have discharged. My signature below certifies that: (1) I have read and understand the definitions, documentation requirements, and terms and conditions that apply to this loan discharge, as specified in Sections 8-10 on the following pages, and that I meet the requirements for loan discharge: (2) The eligible public servant or other eligible victim identified in Section 5 was present at the World Trade Center in New York City, New York, at the Pentagon in Virginia, or at the Shanksville, Pennsylvania site at the time of the terrorist-related aircraft crashes on September 11, 2001, or in the immediate aftermath, in accordance with the definitions in Section 8; and (3) Under penalty of perjury, all of the information I have provided on this form and in any accompanying documentation is true and accurate to the best of my knowledge and belief.

Signature of Borrower

Date

Printed Name of Borrower

Borrower Name: __________________________________ Borrower SSN: |__|__|__|-|__|__|-|__|__|__|__|

SECTION 5: ELIGIBLE PUBLIC SERVANT OR OTHER ELIGIBLE VICTIM INFORMATION

Enter the name, date of birth, and social security number of the eligible public servant or other eligible victim:

|__|__|-|__|__|-|__|__|__|__|

|__|__|__|-|__|__|-|__|__|__|__|

Name (last, first, middle initial; please print)

Date of Birth (mm-dd-yyyy)

Social Security Number

SECTION 6: ELIGIBLE PUBLIC SERVANT/ELIGIBLE VICTIM UNDERSTANDINGS, AUTHORIZATION, AND CERTIFICATIONS

I understand that the borrower identified above and in Section 1 of this form is applying for a discharge of his or her eligible loans on the basis that I became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001. I further understand that, except in the case of a consolidation loan for which the borrower and I are jointly responsible, a discharge of the borrower’s loans based on my permanent and total disability does not discharge any of my loans. If I have other loans for which I am responsible and I have not already applied for or received a discharge of those loans based on my disability, I should contact my loan holder. I authorize any physician, hospital, or other institution having records about the disability that is the basis for the borrower’s request for a loan discharge to make information from these records available to the borrower and to the holder(s) of the borrower’s loan(s) for purposes of this application for a loan discharge. I certify that I became permanently and totally disabled due to injuries suffered in the September 11, 2001 terrorist attacks, as defined in Section 8 of this form. Under penalty of perjury, I further certify that any information I have provided on this form and in any supporting documentation is true and accurate to the best of my knowledge and belief.

Signature of Eligible Public Servant/Eligible Victim or Representative

Date

Printed Name of Eligible Public Servant/Eligible Victim or Representative

SECTION 7: PHYSICIAN’S CERTIFICATION OF PERMANENT AND TOTAL DISABILITY

Instructions for Physician: The borrower identified in Section 1 of this form is applying for discharge of his/her federal education loan(s) on the basis that the borrower is the spouse or parent of an individual (identified in Section 5 of this form) who became permanently and totally disabled due to injuries suffered in the September 11, 2001 terrorist attacks. Complete and sign the certification below only if you are a doctor of medicine or osteopathy legally authorized to practice in a State and if the individual identified in Section 5 of this form became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001, in accordance with the definition in Section 8 of this form (see below). Return the completed form to the borrower identified in Section 1. I certify that the individual identified in Section 5 became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001, in accordance with the definition in Section 8 of this form. I am a doctor of (check one) medicine osteopathy legally authorized to practice in the State of ____________________. (For this purpose, the term State includes the 50 United States, the District of Columbia, American Samoa, the Commonwealth of Puerto Rico, Guam, the Virgin Islands, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau.) My professional license number is ____________________________________________. (Subject to verification through State records.)

Physician’s Signature (a signature stamp is not acceptable)

Date

Printed Name of Physician

Address

City, State, Zip

( )

( )

Telephone

Fax (optional)

E-mail address (optional)

SECTION 8: DEFINITIONS

 Died due to injuries suffered in the terrorist attacks on September 11, 2001 means that the individual identified in Section 5 of this form was present at the World Trade Center in New York City, New York, at the Pentagon in Virginia, or at the Shanksville, Pennsylvania site at the time of or in the immediate aftermath (see below) of the terrorist-related aircraft crashes on September 11, 2001, and the individual died as a direct result of these crashes.  Became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001 means that the individual identified in Section 5 of this form was present at the World Trade Center in New York City, New York, at the Pentagon in Virginia, or at the Shanksville, Pennsylvania site at the time of or in the immediate aftermath (see below) of the terrorist-related aircraft crashes on September 11, 2001, and the individual became permanently and totally disabled as a direct result of these crashes. If the injuries suffered due to the terrorist-related aircraft crashes did not make the individual permanently and totally disabled at the time of or in the immediate aftermath (see below) of the attacks, the individual may be considered to be permanently and totally disabled for the purposes of this loan discharge if the individual’s medical condition has deteriorated to the extent that the individual is now permanently and totally disabled. An individual is considered to be permanently and totally disabled if (a) the disability is the result of a physical injury to the individual that was treated by a medical professional within 72 hours after the injury was sustained or within 72 hours of the individual’s rescue; (b) the physical injury that caused the disability is verified by contemporaneous medical records created by or at the direction of the medical professional who provided the medical care; (c) the individual is unable to work and earn money due to the disability; and (d) the disability is expected to continue indefinitely or result in death.  Present at the World Trade Center in New York City, New York, at the Pentagon in Virginia, or at the Shanksville, Pennsylvania site means that at the time of the terrorist-related aircraft crashes or in the immediate aftermath (see below), the individual identified in Section 5 of this form was physically present (a) in the buildings or portions of the buildings that were destroyed as a result of the terrorist-related aircraft crashes; or (b) in any area contiguous to the crash site that was sufficiently close to the site that there was a demonstrable risk of physical harm resulting from the impact of the aircraft or any subsequent fire, explosions or building collapses. Generally, this includes the immediate area in which the impact occurred, fire occurred, portions of buildings fell, or debris fell upon and injured persons. This definition also includes individuals who were on board American Airlines flights 11 or 77 or United Airlines flights 93 or 175 on September 11, 2001.  Immediate aftermath means, except for eligible public servants, the period of time from the aircraft crashes until 12 hours after the crashes. In the case of an eligible public servant, the immediate aftermath includes the period from the aircraft crashes until 96 hours after the crashes. Definitions continued on page 3.

SECTION 8: DEFINITIONS (continued from page 2)

 The September 11, 2001 terrorist attacks are the terrorist events and their immediate aftermath at the World Trade Center in New York City, New York, the Pentagon in Virginia, the crash site in Shanksville, Pennsylvania, and on board American Airlines flights 11 and 77 and United Airlines flights 93 and 175.

 A spouse of an eligible public servant or other eligible victim must have been married to the eligible public servant or other eligible victim on September 11, 2001 and must currently be married to that individual, or must have been married to that individual at the time of the individual’s death.

 Eligible public servant means an individual who (a) served as a police officer, firefighter, other safety or rescue personnel, or as a member of the Armed Forces, and (b) died or became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001.

 Eligible victim means an individual who died or became permanently and totally disabled due to injuries suffered in the terrorist attacks on September 11, 2001, except for an individual who has been identified as a participant or conspirator in the terrorist-related crashes on September 11, 2001.

 Eligible parent means an individual who owes a Federal PLUS Loan or a Direct PLUS Loan obtained on behalf of an eligible victim, or who owes a Federal Consolidation Loan or a Direct Consolidation Loan that was used to repay a Federal PLUS Loan or a Direct PLUS Loan obtained on behalf of an eligible victim. NOTE: An eligible parent who owes a loan obtained on behalf of an eligible public servant may qualify for a loan discharge in accordance with the requirements for loan discharge based on the death or permanent and total disability of an eligible victim.

 The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans (both subsidized and unsubsidized), Federal Supplemental Loans for Students (SLS), Federal PLUS Loans, and Federal Consolidation Loans.

 The Federal Perkins Loan (Perkins Loan) Program includes Federal Perkins Loans, National Direct Student Loans (NDSL), and National Defense Student Loans (NDSL).

 The William D. Ford Federal Direct Loan (Direct Loan) Program includes Federal Direct Stafford/Ford Loans (Direct Subsidized Loans), Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans), Federal Direct PLUS Loans (Direct PLUS Loans), and Federal Direct Consolidation Loans (Direct Consolidation Loans).

 An eligible loan for the purpose of this loan discharge is (1) any outstanding FFEL, Direct Loan, or Perkins Loan program loan on which amounts were owed by the borrower on September 11, 2001; or (2) the outstanding portion of a Federal Consolidation Loan or Direct Consolidation Loan attributable to FFEL, Direct Loan, or Federal Perkins Loan program loans that were owed on September 11, 2001.

 The holder of your FFEL Program loan(s) may be a lender, a guaranty agency, or the U.S. Department of Education (ED). The holder of your Perkins Loan Program loan(s) may be a school you attended or ED. The holder of your Direct Loan Program loan(s) is ED.

SECTION 9: DOCUMENTATION REQUIREMENTS

A. For the death of an eligible public servant:

1. A certification from an authorized official of the Armed Forces, police, fire, or safety/rescue agency (for example, military commanding or personnel officer, or human resources official) that the individual identified in Section 5 of this form was a member of the Armed Forces, or was employed as a police officer, firefighter, or other safety or rescue personnel, and was present at the World Trade Center in New York City, New York, at the Pentagon in Virginia, or at the Shanksville, Pennsylvania site at the time of the terrorist-related aircraft crashes or in the immediate aftermath of these crashes; and

2. Documentation that the individual identified in Section 5 of this form is included on an official list of the individuals who died in the September 11, 2001 terrorist attacks; or, if the individual is not included on such a list –

• An original or certified copy of the individual’s death certificate or, if the individual owed a FFEL, Direct Loan, or Federal Perkins Loan program loan at the time of the terrorist attacks, documentation that the individual’s loan was discharged by the loan holder due to death; and

• A certification from a physician or medical examiner that the individual died due to injuries suffered in the terrorist attacks on September 11, 2001; or

3. In exceptional circumstances and on a case-by-case basis, other reliable documentation in lieu of the documentation specified in A.1. and/or A.2 of this section, as determined by the chief executive officer of the guaranty agency (for FFEL Program loans), the chief financial officer of the school (for Perkins Loan Program loans), or the Secretary of Education (for Direct Loan Program loans).

B. For the death of an eligible victim :

• The documentation specified in A.2. or A.3. of this section.

C. For the permanent and total disability of an eligible public servant:

1. The documentation specified in A.1. of this section;

2. Copies of contemporaneous medical records created by or at the direction of a medical professional who provided medical care to the individual identified in Section 5 of this form within 72 hours after the injury was sustained or within 72 hours after the individual was rescued (a “contemporaneous” medical record means a record that was created at the time the medical care was provided); and

3. A certification in Section 7 of this form by a physician, who is a doctor of medicine or osteopathy and who is legally authorized to practice in a State, that the individual identified in Section 5 of this form is permanently and totally disabled as a result of injuries suffered in the terrorist attacks on September 11, 2001.

D. For the permanent and total disability of an eligible victim :

• The documentation specified in C.2. and C.3. of this section.

SECTION 10: LOAN DISCHARGE TERMS AND CONDITIONS

 If you qualify for loan discharge as a September 11, 2001 survivor, you are relieved of the obligation to make further payments on your eligible loans, in accordance with the terms specified below. Any payments you made on a loan prior to discharge are not returned.

 If you are the spouse of an eligible public servant, you are relieved of the obligation to make further payments on any of your eligible loans, including any eligible Federal Consolidation Loan or Direct Consolidation Loan that was made jointly to you and the eligible public servant.

 If you are the spouse of an eligible victim (other than an eligible public servant), you are relieved of the obligation to make further payments on the portion of a Federal Consolidation Loan or a Direct Consolidation loan made jointly to you and the victim that is attributable to the victim’s eligible loans. You will remain responsible for repaying the portion of the consolidation loan that is attributable to your loans.

 If you are the parent of an eligible victim, you are relieved of the obligation to make further payments on (1) an eligible Federal PLUS Loan or Direct PLUS Loan that you obtained on behalf of the victim, and (2) the portion of a Federal Consolidation Loan or a Direct Consolidation Loan that is attributable to eligible Federal PLUS Loans or Direct PLUS Loans you obtained on behalf of the victim.

SECTION 11: WHERE TO SEND THE COMPLETED LOAN DISCHARGE APPLICATION
Send the completed loan discharge application and any attachments to: (If no address is shown, return to your loan holder.)	If you need help completing this form, call:
SECTION 12: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: Sections 421 et seq., 451 et seq., and 461 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., and 20 U.S.C. 1087aa et seq.), and §6 of the Third Higher Education Extension Act of 2006 (THEEA), Pub. L. 109-292, provide the authorities for collecting the requested information from and about you and about your spouse or child who is an eligible public servant or eligible victim as defined in §6(a)(1) and (2) of the THEEA. The authorities for collecting and using your Social Security Number (SSN) and the SSN of your spouse or child who is an eligible public servant or eligible victim, as defined in §6(a)(1) and (2) of the THEEA, are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)), 31 U.S.C. 7701(b), and §6 of the THEAA. Participating in the Federal Family Education Loan (FFEL) Program, the William D. Ford Federal Direct Loan (Direct Loan) Program, or the Federal Perkins Loan (Perkins Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate. The principal purposes for collecting the information on this form, including your SSN and the SSN of your spouse or child who is an eligible public servant or eligible victim as defined in §6(a)(1) and (2) of the THEEA, are to verify your identity and the identity of the eligible public servant or eligible victim, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the FFEL, Direct Loan, and/or Perkins Loan Programs, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. We also use your SSN as an account identifier and to permit you to access your account information electronically. The information in your file may be disclosed, on a case-by-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions to efficiently submit student enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies. In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0079. The time required to complete this information collection is estimated to average 1 hour (60 minutes) per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4700. Do not send the completed loan discharge application to this address. If you have questions regarding the status of your individual submission of this form, contact your loan holder (see Section 11).

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Loan Discharge Application: September 11, 2001 Survivor DRAFT 07-10-2007