Federal Perkins Loan Progrm NDSL Assignment Form: Instit

According to the Paperwork Reduction Act of 1995, no persons are required to respond to collection
information unless such collection displays a valid OMB control number. The valid OMB control
number for this information collection is 1845-0048. The time required to complete this information
collection is estimated to average 24 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions
for improving this form, please write to U.S. Department of Education, Washington, D.C. 202024651. If you have comments or concerns regarding the status of your individual submission of this
form, write directly to Federal Student Aid, U.S. Department of Education, Operation Services,
Processing Division, Perkins Loan Assignments, 50 Beale Street, Suite 8601, San Francisco, CA
94501.

OMB Number 1845-0048
Form Approved
Expiration Date: XXXXXXX

Federal Perkins Loan Program/NDSL
Assignment Form: Institutional Certification
The borrower(s) named on the attached manifest received Federal Perkins Loan Program, National Direct Student Loan Program, or National
Defense Student Loan Program loan(s) authorized under Title IV, Part E, of the Higher Education Act of 1965, as amended, or authorized
under Title II of the National Defense Education Act. The institution is assigning all rights and title under such note or agreement to the
United States Department of Education, without recompense as provided under Section 463(a)(5), 20 U.S.C. 1087cc.
SECTION A – INSTITUTIONAL INFORMATION
1. Name of Institution

2. Serial Number

3. Street Address of Institution

4. City

5. State

6. Zip Code

SECTION B – CERTIFICATION
I understand that if I knowingly make a false statement or misrepresentation on this form in the course of assigning loans to the United States
Department of Education, I am subject to a fine of up to $10,000 or imprisonment of up to five (5) years or both under provisions of the United
States Criminal Code, 18 U.S.C. 1001.
7. Typed Name of Authorized Official

8. Telephone Number
(
)

9. Typed Title of Authorized Official

10. Alternate Contact

11. Signature of Authorized Official

12. Certification Date (MM/DD/YYYY)

SECTION C – MANIFEST
Instructions: Attach a manifest to this form listing the loans that are being assigned. The institution name and Serial Number must appear at
the top of each page of the manifest. The manifest must be in the following format:
Borrower’s Name and
Social Security Number

Loan Type

Interest Rate

Total Amount Outstanding
(Section D, Item # 37)

Date(s) of First Disbursement

Under “Loan Type” indicate P for Perkins Loans, I for National Direct Student Loans, and E for National Defense Student Loans. If a
borrower has loans of different types and interest rates, list each loan separately. NOTE: “Date(s) of First Disbursement” for each loan
listed on the manifest must match the date of first disbursement initially reported to NSLDS. See Detailed Instructions.

Federal Perkins Loan Program/NDSL
Assignment Form: Borrower and Loan Information

OMB Number: 1845-0048
Form Approved
Expiration Date: XXXXX

SECTION A – BORROWER INFORMATION
1. Current or Last Known Name (Last, First, MI)
3. Social Security Number

2. Previous Name(s) (Optional)
4. Date of Birth (MM/DD/YYYY)

5. Departure Date (MM/DD/YYYY)

6. Current or Last Known Permanent Address (Number and Street)

7. Telephone Number
(
)

8. City

10. Zip Code

9. State

SECTION B – COSIGNER INFORMATION (Complete if applicable)
11. Name of Cosigner of Loan (Last, First, MI)

12. Social Security Number of Cosigner
(Optional)

13. Current or Last Known Permanent Address of Cosigner (Number and Street)

14. Telephone Number
(
)

15. City

17. Zip Code

16. State

SECTION C- LOAN INFORMATION: HISTORICAL
18. Type of Loan (Check appropriate space)
Perkins ___

19. Applicable Interest Rate on the Loan

Direct ___ Defense ___

20. Date of Last Advance (MM/DD/YYYY)

_______%
21. Date Last Grace Period Ended
(MM/DD/YYYY)

22. Date of Default (MM/DD/YYYY)

23 Was this loan ACCELERATED? (Check appropriate space.)
If YES, provide date of acceleration. If NO, provide date this loan became fully mature (due-in-full).
YES ___

NO ___

Date (MM/DD/YYYY) ________________

24. Was this loan LITIGATED? (Check appropriate space.) If YES, provide date and attach judgement.
YES ___

NO ___

Date (MM/DD/YYYY) ________________

25. Borrower Repayment status (For use only by schools closing out program)
________________________________
26. Reason this loan is being assigned or has been determined uncollectible. (Check appropriate space)
Hardship _____

Incarceration ___

Unemployment ___

Liquidation _____

Refusal to Pay ___

Address Unknown ___

Total and Permanent Disability _____ Other (Please Explain) _____________

SECTION D – LOAN INFORMATION: FINANCIAL
27. Principal Amount Loaned (Not Refunds)
$ ________________

28. Principal Amount Adjusted
$ ____________

29. Principal Amount Repaid
$ ___________________

30.Principal Amount Cancelled

32. Collection Costs Repaid

$ __________________

31. Principal Amount Outstanding
(27 less 28, 29, & 30)
$ ____________________

33. Interest Repaid
$ ____________

34. Interest Cancelled
$ ________

35. Interest Due
$ ____________

36. Collection Costs/Penalty/Late Charges

37. Total Amount Outstanding (Sum of Items 31, 35, and 36)

$ __________

$ ___________

$ ________________

SECTION E – CANCELLATION INFORMATION (Optional)

Cancellations Granted for this Loan

38.
Type of Cancellation

39.
Percentage
Rate

.

40.
Principal
Cancelled

41.
Interest
Cancelled

.

42.
Cancellation Service
Start Date

43.
Cancellation Service
End Date

(MM/DD/YYYY)

(MM/DD/YYYY)