| LENDER'S APPLICATION FOR PAYMENT OF INSURANCE CLAIM |
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OMB NO. 1845-0042 |
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EXPIRATION: |
| 1. BORROWER SECTION |
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| 1. SOCIAL SECURITY NUMBER |
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2. NAME OF BORROWER (LAST, FIRST, MI, MAIDEN) |
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3. TELEPHONE NUMBER |
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| 4. LAST KNOWN STREET ADDRESS CITY STATE ZIP CODE |
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| II. LENDER SECTION |
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| 5. LENDER ID |
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6. LENDER NAME |
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7. LENDER TELEPHONE NUMBER |
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| 8. LENDER ADDRESS CITY STATE ZIP CODE |
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9. CONTACT PERSON |
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| III. CLAIM SECTION |
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| 10. CHECK THE REASON FOR CLAIM |
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11. CHECK TYPE OF LOAN |
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| _____ (0) CLOSED SCHOOL |
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____ A. FEDERALLY INSURED STUDENT LOAN |
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| _____ (1) DEFAULT - IS THERE A "CURE"? YES ___ |
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____ B. STAFFORD (FFEL) |
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| _____ (2) BANKRUPTCY WITH 7 YRS IN REPAYMENT (CH 7 & 11) |
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____ C. UNSUBSIDIZED STAFFORD |
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| _____ (3) DEATH |
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____ D. SLS |
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| _____ (4) PERMANENT AND TOTAL DISABILITY |
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____ E. CONSOLIDATION |
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| _____ (5) BANKRUPTCY LESS THAN 7 YRS IN REPAYMENT (CH 7 & 11) |
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____ F. PLUS |
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| _____ (6) FALSE CERTIFICATION |
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____ G. OTHER |
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| _____ (7) BANKRUPTCY CHAPTER 13 |
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| _____ (8) BANKRUPTCY CHAPTER 12 |
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| 12. DATE STUDENT CEASED AT |
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13. LAST DAY OF |
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14. DATE FIRST |
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| LEAST HALF-TIME STUDY ________________ |
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GRACE PERIOD _____________ |
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PAYMENT DUE ____________ |
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MM/DD/YY |
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MM/DD/YY |
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MM/DD/YY |
| 15. DUE DATE OF MOST |
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16. LAST DATE INTEREST |
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| DELINQUENT PAYMENT_______________ |
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WAS PAID OR CAPITALIZED _________________ |
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MM/DD/YY |
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MM/DD/YY |
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| 17. GUARANTOR'S NAME |
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ADDRESS CITY STATE ZIP CODE |
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18. GUARANTOR'S TELEPHONE NUMBER |
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| IV. LOAN INFORMATION (For each loan, list the first actual disbursement date and unpaid principal balance) |
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| 19. Date of Disbursement |
20. Amount of Disbursement |
21. Annual Interest Rate |
22. Amount of Capitalized Interest |
23. Unpaid Principal Balance |
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Department of Education Use Only |
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| Totals |
$ |
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$ |
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| V. COSIGNER/ENDORSER INFORMATION (If applicable) |
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| 24. LAST NAME FIRST NAME MI MAIDEN NAME |
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25. TELEPHONE NUMBER |
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| 26. ADDRESS CITY STATE ZIP CODE |
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| 27. LAST NAME FIRST NAME MI MAIDEN NAME |
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28. TELEPHONE NUMBER |
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| 29. ADDRESS CITY STATE ZIP CODE |
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| I certify that all the information provided in connection with this claim is true and correct and that this claim fully complies with the provisions of Title IV, Part B of the Higher Education Act of 1965, as amended (the Act) |
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| and all statues and regulations applicable to the Federal Family Education Loan Program. I also certify that the loan satisfies all the requirements for payment under the Act and regulations and that (1) if I am filing a |
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| default claim, the borrower is not eligible for a deferment: and (2) the loan has been serviced in compliance with the Department of Education's regulations for due diligence in 34 C.F.R. Part 682. If I receive any |
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| payments related to this claim after I have submitted this form, I agree to send the money received to the Department of Education after the Department has paid the claim. |
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| 30. SIGNATURE OF OFFICER |
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31. TYPED NAME AND TITLE |
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32. DATE OF APPLICATION FOR INSURANCE CLAIM |
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DO NOT WRITE BELOW THIS LINE (FOR ED use only) |
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| DATE OF DEFAULT |
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SLIP DATE |
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APPROVED BY |
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DATE APPROVED |
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| ED FORM 1207 |
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