Alternative Documentation of Income

OMB No. 1845-0016

Form Approved

Exp. Date xx/xx/xxxx

Income Contingent Repayment Plan & Income-Based Repayment Plan

Alternative Documentation of Income

William D. Ford Federal Direct Loan Program

Federal Direct Stafford/Ford Loans, Federal Direct Unsubsidized Stafford/Ford Loans,

Federal Direct Subsidized Consolidation Loans, Federal Direct Unsubsidized Consolidation Loans

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form shall 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: Identifying Information

Before completing this form, carefully read the instructions in Section 5.

All borrowers must provide the Borrower Information below.		If you are married, you must also provide the Spouse Information below if (1) you are repaying under the ICR Plan, or (2) you are repaying under the IBR Plan and you and your spouse file a joint federal tax return.
Borrower Information:		Spouse Information:
Borrower’s Name (please print clearly):		Your Spouse’s Name (please print clearly):
________________________________________________ Last Name First Name Middle Initial		________________________________________________________ Last Name First Name Middle Initial
Borrower’s Social Security Number: |__|__|__|-|__|__|-|__|__|__|__|		Your Spouse’s Social Security Number: |__|__|__|-|__|__|-|__|__|__|__|

Section 2: Borrower’s Income Information – to be completed by ALL BORROWERS

All borrowers must complete this section.

You must list all taxable income you are currently receiving (i.e., income from employment, unemployment income, dividend income, interest income, tips, alimony). Include the amount of money received, how often you receive this money, and your employer (if any) or the source of your income if you are not employed. You must attach supporting documentation for all income reported in this section (e.g., pay stubs, letters from your employer stating your income, interest or bank statements, dividend statements, canceled checks, or, when these forms of documentation are unavailable, a signed statement explaining your income source(s) and giving the addresses of these sources). Copies are acceptable, but all supporting documentation must be no more than 90 days old. If you have more than two sources of income, provide the information requested in this section on a separate piece of paper and mail it with this form. Do not report untaxed income such as Supplemental Security Income, child support, or federal or state public assistance. If your income or the income of your spouse changes significantly after your submission of this form, you must notify the Direct Loan Servicing Center of this change (see contact information in Section 5).

Amount of Income

Frequency of Payment (Please check the appropriate box.)

Employer or Source of Income

Weekly

Bi-weekly

Semi-monthly

Monthly

Yearly

$











$











 Check this box if you do not have any taxable income and receive only untaxed income such as Supplemental Security Income, child support, or federal or state public assistance.

Section 3: Spouse’s Income Information – to be completed by SOME MARRIED BORROWERS

If you are married, you must provide your spouse’s income information if:

1. You are repaying under the ICR Plan, or

2. You are repaying under the IBR Plan and you and your spouse file a joint federal tax return.

If you are required to complete this section, you must provide the same information and supporting documentation for your spouse’s income that is required for your own income, as explained above in Section 2.

Amount of Income

Frequency of Payment (Please check the appropriate box.)

Employer or Source of Income

Weekly

Bi-weekly

Semi-monthly

Monthly

Yearly

$











$











 Check this box if your spouse does not have any taxable income and receives only untaxed income such as Supplemental Security Income, child support, or federal or state public assistance.

Section 4: Certification and Signature

All borrowers must complete this section. If you are married, your spouse must sign and date below only if (1) you are repaying under the ICR Plan, or (2) you are repaying under the IBR Plan and you and your spouse file a joint federal tax return.

Certification: I certify that all of the information reported in Section 2 and, if applicable, Section 3 is true and complete to the best of my knowledge. I agree to provide to the U.S. Department of Education (the Department) on an annual basis (or as required by the Department) alternative documentation of my income for the purpose of determining my appropriate repayment amount under the ICR Plan or IBR Plan. I understand that (1) if I do not provide this information the Department will base my ICR or IBR amount on my AGI, as reported by the IRS, or, in some instances, I will not be allowed to repay my loan(s) under the ICR or IBR Plan; (2) the Department may request my income information from the IRS even if alternative documentation of my income is accepted; and (3) if I am married, my spouse’s income information, documentation, and signature are also required if I am repaying under the ICR Plan, or if I am repaying under the IBR Plan and my spouse and I file a joint federal tax return.

Borrower’s Signature

Date of Borrower’s Signature

Spouse’s Signature

Date of Spouse’s Signature

Section 5: Instructions and Where to Send the Completed Form

INSTRUCTIONS:

YOU ARE REQUIRED to complete this form if you are repaying your Direct Loans under the Income Contingent Repayment (ICR) or the Income-Based Repayment (IBR) Plan and:

• You are in your first year of repayment;

• You are in your second year of repayment and have been notified that alternative documentation of your income is required; or

• You have been notified that the Internal Revenue Service (IRS) is unable to provide the U.S. Department of Education (the Department) with your Adjusted Gross Income (AGI) or that of your spouse (if applicable).

YOU MAY complete this form if:

• You are repaying your Direct Loans under the ICR Plan and your AGI (and your spouse’s AGI, if you are married), as reported on your most recently filed federal tax return, does not reasonably reflect your current income (e.g., due to circumstances such as loss or change in employment by you or your spouse).

• You are repaying your Direct Loans under the IBR Plan and your AGI (and your spouse’s AGI, if you and your spouse file a joint federal tax return), as reported on your most recently filed federal tax return, does not reasonably reflect your current income (e.g., due to circumstances such as loss or change in employment by you or your spouse).

In cases where alternative documentation of your income is used, the amount of your monthly payment under the ICR or IBR Plan is based on the current income information you and your spouse (if applicable) provide and is reevaluated annually. Your monthly payment may be adjusted more frequently than annually if you notify the Direct Loan Servicing Center that your AGI (or your spouse’s AGI, if you file a joint federal tax return) has changed significantly since your most recent submission of this form and you provide supporting documentation showing this change. To submit alternative documentation of your income, you must attach the required documentation, complete and sign this form, and return it to the address below. If you are married, your spouse must also complete and sign the applicable sections of this form and submit the required documentation if (1) you are repaying your loans under the ICR Plan, or (2) you are repaying your loans under the IBR Plan and you and your spouse file a joint federal tax return. If you need assistance, please call 1-800-848-0979, or TDD 1-800-848-0983.

Return this form to:

U.S. Department of Education

Direct Loan Servicing Center

P.O. Box 5609

Greenville, TX 75403-5609

If you need assistance in completing this form, call 1-800-848-0979. Individuals who use a telecommunications device for the deaf (TDD) may call 1-800-848-0983.

Section 6: Important Notices

PRIVACY ACT NOTICE

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you:

The authority for collecting the requested information from and about you is §451 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the William D. Ford Federal Direct Loan (Direct 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, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the Direct Loan Program, 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 1845-0016. The time required to complete this information collection is estimated to average 0.33 hours (20 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 20202-4537. Do not send the completed form to this address.

If you have questions about the status of your individual submission of this form, contact the Direct Loan Servicing Center at the following address:

U.S. Department of Education

Direct Loan Servicing Center

P.O. Box 5609

Greenville, TX 75403-5609