Form 513

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

Rockville, MD 20857

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN PROGRAM REQUEST FOR COLLECTION ASSISTANCE

(42 U.S.C. 292-2920)

FORM APPROVED:

OMB No. 0915-0036 Exp. Date:

D ATE OF REQUEST

Public Burden Statement: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a valid OMS control number. The valid OMB control number for this information collection is 0915-0036. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. 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 10-33, Rockville, Maryland, 20857.
FROM: (Name of Lender)			LENDER IDENTIFICATION			SERVICER IDENTIFICATION		TO: Debt Management Branch, PSC Health and Human Services 5600 Fishers Lane, Room 8A-45 Rockville, MD 20857
			CITY AND STATE				ZIP CODE
STREET ADDRESS
NAME AND TITLE							TELEPHONE
							AREA CODE	I NUMBER
We request your assistance on the Delinquent Borrower below:
NAME OF BORROWER (Last, First, MI)		DISCIPLINE ---- --- ----		SOCIAL SECURITY NUMBER			TELEPHONE
							AREA CODE	NUMBER
MAILING ADDRESS - STREET				CITY			STATE	ZIP CODE
LAST SCHOOL ATTENDED				SCHOOL IDENTIFICATION			DATE OF SCHOOL □ Graduation ____________________________________ □ Withdrawal ____________________________________
NAME OF NEAREST RELATIVE		ADDRESS (STREET)
		(CITY)					(STATE)	(ZIP CODE)
NAME OF PARENT OR GUARDIAN		ADDRESS (STREET)
		(CITY)					(STATE)	(ZIP CODE)
ORIGINAL PRINCIPAL LOAN AMOUNT	UNPAID PRINCIPAL AND INTEREST				PERCENT INTEREST			NUMBER OF PAYMENTS MADE TO DATE
REASON FOR THIS REQUEST (Check one) 1. □ STUDENT IS DELINQUENT ON MONTHLY PAYMENTS NUMBER OF PAYMENTS AMOUNT DUE PER MONTH
2. □ SKIP
3. □ OTHER (Explain)
WARNING: Any person who knowingly makes a false statement or misrepresentations in a HEAL loan transaction, bribes or attempts to bribe a Federal official, fraudulently obtains a HEAL loan, or commits any other illegal action in connection with a HEAL loan is subject to possible fine and imprisonment under Federal statute.

HRSA-513 (9/05)