Form 510

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

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

LENDER’S APPLICATION FOR INSURANCE CLAIM

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 OMB 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 30 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.

General Information

The amount of Federal insurance payment received depends upon whether there is compliance with HEAL statute, regulations, and policies, including those concerned with the making, servicing, and collection of the loan or loans, and the timely submission of documents (See Sections 60.13 and 60.38 through 60.41.)

The following documents will assist you in completing this form: (1) HEAL Statute and Regulations; (2) Copy of borrower’s application(s); (3) Original Promissory Note(s); (4) Copy of disbursement check(s); (5) Copy of borrower’s deferment request(s); (6) Evidence of student enrollment status and date of separation; (7) Repayment schedule(s); (8) Copy of borrower’s forbearance request(s); (9) Litigation, bankruptcy, death, or disability documents; and

(10) Payment and servicing history of borrower’s account.

Instructions for completing the form

Item 1a: Holder (owner) of the HEAL loans. Provide six-digit holder identification number, institution’s name, address, city, state, zip code, telephone number, including area code, and fax number.

Item 1b: Servicer may be the same organization as the holder or a different organization. This is where the loans are being serviced. Provide six-digit holder identification number, institution’s name, address, city, state, zip code, telephone number, including area code, and fax number.

Item 1c: Claim Type. Place an “X” in the appropriate box that reflects the type of claim submitted.

Item 2: Provide borrower’s name (if name has changed enter former name in parentheses), social security number, last known address, including city, state, name of foreign country borrower resides (if applicable) and zip code.

Item 3: Provide 12-digit HEAL Loan ID Number for each loan included in the claim, original loan and disbursed amount. For each loan ID number listed the holder must check appropriate columns as to documents included in the claim package under promissory note, application, repayment schedule, payment history, principal/interest calculation worksheet, and the number of months in deferment and forbearance.

Item 4: Claim Information. Complete all information requested regarding dates, yes or no answers by placing an “X” in the appropriate box.

NOTE: Go to Item 5, 6, 7, 8, 9, 10, or 11 according to claim type selected.

Item 5: Judgment Claim. Fill in all information requested.

Item 6: Bankruptcy Claim. Fill in all information requested.

Item 7: Skip Claim. Fill in all information requested.

Item 8: Unable to Serve Claim. Fill in all information requested.

Item 9: Disability Claim. Fill in all information requested.

Item 10: Death Claim. Fill in all information requested.

Item 11: Low Balance Claim. Fill in all information requested.

Item 12: Enter the total amount of principal and interest for all loans claimed.

Item 12a: Self-explanatory.

The following must be completed before submitting the form:

-- Assigned promissory note(s) to the United States Government.

-- Certified copy of the judgment and original assignment of the judgment to the United States Government.

-- A signed claim form with supporting documentation.

Send original and 2 copies of the claim form and all documentation to:

Health Education Assistance Loan Program

Parklawn Building, Room 8-37

5600 Fishers Lane

Rockville, Maryland 20857

L

FORM APPROVED:

OMB NO.0915-0036

Exp. Date:

ENDER’S APPLICATION FOR INSURANCE CLAIM ON A FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL)

WARNING: Any person who knowingly makes a false statement or misrepresentation 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 Statue.

1a. HOLDER INFORMATION

1b. SERVICER INFORMATION

Holder ID Number:_____________________________ Holder Name: _________________________________ Address: _____________________________________ City/State/Zip Code:_______________________________ Telephone No.: _____________ Fax: ____________

Servicer ID Number:_______________________­­ Servicer Name: ________________­­­_________­­­­­­­__ Address: ________________________________ City/State/Zip Code: _________________________ Telephone No.: _____________ Fax: ­­­________

Original Claim Submission YES □ NO □ If no, date on DHHS letter rejecting original claim submission:

1c. CLAIM TYPE

Judgment □

Bankruptcy Chapter 11 □

Bankruptcy Chapter 13 □

Bankruptcy Adversary □

Skip □

Unable to Serve □

Disability □

Death □

Low Loan Amount □

2. BORROWER INFORMATION

BORROWER NAME (Last, First, M.I.)

SOCIAL SECURITY NO.

LAST KNOWN ADDRESS

CITY

STATE OR FOREIGN COUNTRY

ZIP CODE

3. HEAL LOAN INFORMATION AND DOCUMENTATION (Complete all columns for each loan listed.)

Loan ID Number

Original Loan Amount Guaranteed

Amount Disbursed

Promissory Note (Check one column)

Application (Check one column)

Repayment Schedule

Payment History (Check for yes)

Principal & Interest Worksheet (Check for Yes)

No. of Months in Deferment

No. of Months in Forbearance

Original

Copy with Affidavit

Original

Copy with Affidavit

Copy

Affidavit

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HRSA – 510 Page 1

Rev.9/2008

Borrower Name (Last, First, M.I.)

Social Security No.

4. Claim Information

Borrower School Separation Date

Repayment Begin Date

Refinanced Loan Yes □ No □

Most Recent Delinquency Date

Date Reported Credit Bureau

Due Diligence Letter 1 Date

Due Diligence Letter 2 Date

Due Diligence Letter 3 Date

Due Diligence Letter 4 Date

PRIOR BANKRUPTCY YES □ NO □

PCA 90 Day Letter Date

PCA 120 Day Letter Date

PCA 150 Day Letter Date

FINAL DEMAND DATE

5. Judgment Claim

Date Litigation Began

Litigation ID Number

Date of Judgment

DATE Judgment assignment

Date exemplified or Certified judgment received

Post-Judgment Interest Rate (Percent Only)

Continuing Interest Clause? Yes □ No □

6. Bankruptcy Claim (All Bankruptcy claims must be filed within 10 days of notification and include required documentation.)

Date of official Notification of Bankruptcy

First Meeting of Creditors Included? Yes □ No □

Proof of claim included? Yes □ No □

Transfer of Proof of claim? Yes □ No □

Copy of Bankruptcy Plan included? Yes □ No □

ADVERSARY ONLY

Basis for Objection included? Yes □ No □

Copy of Complaint? YES □ NO □

Date of Complaint

Copy of Summons? YES □ NO □

Date Adversary Received?

7. SKIP

8. UNABLE TO SERVE

Date Skip Tracing Began

Date of Determination

No. of Attempts to Serve

Was Service Attempted by Officers of the Court (Public Service)? Yes □ No □

Return of Service? Yes □ No □

Last Attempt Date

Copy of Complaint Included? Yes □ No □

9. DISABILITY

Date Notified of Disability

Date Package sent to DHHS

Date of DHHS Approval

10. DEATH

Date Notified of Death

Date Official Notification of Death Received

11. LOW LOAN AMOUNT

All loans made prior to 11/14/88 <$5000? Yes □ No □

All loans made on or after 11/4/88<$2500? Yes □ No □

Claim Amount <$1,000? Yes □ No □

12. TOTAL AMOUNT OF INSURANCE CLAIM (Principal and Interest): $_________________________ I certify that the information on this form is correct. I have used standard commercial collection practices and conformed to the due diligence standards of the HEAL regulations and policy guidelines. The borrower is not entitled to the deferment of principal, as provided in the Promissory. Note(s). Any further payments by the borrower will be sent to the Public Health Service.

FOR PHS USE ONLY

12a. SIGNATURE OF AUTHORIZING OFFICIAL

12b. NAME AND TITLE (Please Print)

12c. DATE

HRSA – 510 Page 2

Rev.9/2008