SAFRA Application

OMB NO:

APPLICATION FOR payments to loan servicers for retaining JOBS

Section 458(a)(7) of the Higher Education Act of 1965, as amended (HEA) as added by of the SAFRA Act, which was included in the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), requires the Secretary to make payments to loan servicers for retaining jobs at locations in the United States where such servicers were operating in the Federal Family Education Loan Program (FFELP) under title IV, part B of the HEA on January 1, 2010. The bill authorizes and appropriates $25,000,000 for each of the Federal fiscal years 2010 and 2011 for this purpose. The Secretary will allocate funds directly to eligible entities actively engaged in servicing FFELP loans in the United States as of January 1, 2010 and that meet the requirements for receiving a payment as provided in the Interim Final Requirements Notice. An eligible entity must apply separately for funding for each location at which it conducts business in the United States and at which it would use the funds to retain jobs.

INSTRUCTIONS: You must complete a separate form for each servicing location.

Eligible Entity Name: ____________________________DUNS number_________Servicer I.D.number_________

Corporate Headquarters Address: _________________________________________________________________

Contact Name:___________________________Telephone_________________E-mail______________________

Application Year: FY 2010

Provide the following information as required by and as defined in the Interim Final Requirements Notice:

Location of servicing facility for which funds are being sought:

Address: ______________________________County or County Equivalent: __________________

City: ___________________________State: _____ Zip Code (+4): __________________

Total Employees:		Total Payroll:
Eligible Employees:		Eligible Payroll:

you must complete and return a separate form by the deadline provided in the interim final requirements notice for each servicing location for which you want to receive funds.

Return all application materials as required in the Notice of Interim Final Requirements, including this completed and signed application form, a viable business plan describing how you plan to continue employment of employees who might otherwise lose their jobs due to the termination of new FFELP loan originations and a budget and a timeline outlining how the funds will be used in accordance with this program’s allowable use of funds requirement, to: Donald Conner via E-mail at [email protected] or by fax at 202-502-7875. If e-mailing your application, sign, scan and then email the completed application; or, if faxing your application, sign and fax the completed application. Your application must be received by the Department no later than [insert date].

Certification

By submitting this application form, the applicant servicer certifies that the information provided is accurate and correct and that the funds received will be used only for the allowable purposes described in the Notice of Interim Final Requirements to retain employees who would not otherwise be retained. Funds used for any other purpose must be repaid to the Secretary. The applicant servicer acknowledges that this application is a claim for federal funds provided under the HEA and that any false statement or claim or misrepresentation may be punished under Federal law, including but not limited to 18 U.S.C. §§ 641 & 1001 and 31 U.S.C. §§ 3729 - 3733.

Name of Authorized Official: _________________________ Title: ________________Contact No.: ________________

Signature of Authorized Official: _______________________ Date: ________________________

Paperwork Burden Statement

According to the Paperwork reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1840-NEWA. The time required to complete this information collection is estimated to average 47 hours 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. 20202-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Postsecondary Education, U.S. Department of Education, 400 Maryland Avenue, S.W., K Street, Room 8030, Washington D.C. 20202-4537.