Form 1 513 Form

FORM APPROVED

OMB No. 0915-0036

EXP DATE:

U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Bureau of Health Profession

Rockville, MD 20857

DATE OF REQUEST

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

REQUEST FOR COLLECTION ASSISTANCE

(42 U.S.C. 292-2920)

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 for this information collection is 0915-0036. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

FROM (Name of Lender)

LENDER

IDENTIFICATION

SERVICER IDENTIFICATION

TO: Debt Management Branch, PSC

Health and Human Services

5600 Fishers Lane, Room 11-61

Rockville, MD 20857

STREET ADDRESS

CITY AND STATE

ZIP CODE

NAME AND TITLE

TELEPHONE

AREA CODE

NUMBER

We request your assistance on the Delinquent Borrower below:

NAME OF BORROWER (Last, First, MI)

DISCIPLINE

SOCIAL SECURITY NUMBER

TELEPHONE

AREA CODE

NUMBER

MAILING ADDRESS

CITY

STATE

ZIP CODE

LAST SCHOOL ATTENDED

SCHOOL IDENTIFICATION

SCHOOL DATE

□ Graduation____________________________

□ Withdrawal____________________________

NAME OF NEAREST RELATIVE

ADDRESS

CITY

STATE

ZIP CODE

NAME OF PARENT OR GUARDIAN

ADDRESS

CITY

STATE

ZIP CODE

ORIGINAL PRINCIPAL LOAN AMOUNT

UNPAID PRINCIPAL AND INTEREST

PERCENT INTEREST

NUMBER OF PAYMENTS MADE TO DATE

REASON FOR THIS REQUEST (Check one)

1a. □ STUDENT IS DELINQUENT ON MONTHLY PAYMENTS 1b. REFINANCED LOAN Yes □ No □

NUMBER OF PAYMENTS

AMOUNT DUE PER MONTH $

2. □ SKIP

3. □ OTHER (Explain)

WARNING: Any person who knowingly makes a false statement or misrepresentations 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(s) and imprisonment under Federal statute.

HRSA-513 (9/05)