Alternative Documentation of Income

OMB No. 1845-0016

Draft Form

Exp. Date XX/XX/XX

A DOI

ALTERNATIVE DOCUMENTATION OF INCOME

Income-Contingent and Income-Based Repayment Plans

William D. Ford Federal Direct Loan (Direct Loan) Program

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document is subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: BORROWER IDENTIFICATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN

-

-

Name

Note: Read Section 5 to determine whether you should complete this form.

Address

City, State, Zip Code

Telephone – Primary ( )

Telephone – Alternate ( )

E-mail Address (Optional)

SECTION 2: SPOUSE IDENTIFICATION – To be completed by married borrowers that check box 2, 3, or 4, below.

Check all boxes in this section that apply to you and your spouse.

2.

My spouse and I file a joint Federal tax return

3.

I am requesting or on the ICR Plan and am married

4.

I have a joint Direct Consolidation Loan with my spouse

5. Spouse’s SSN

-

-

6. Spouse’s Name

7. Spouse’s Date of Birth (MM-DD-YYYY)

-

-

SECTION 3: INCOME INFORMATION – To be completed by ALL BORROWERS

Provide the following information about the taxable income you are currently receiving after you have determined (by reading Section 5) that you should complete this form. Taxable income includes income from employment, unemployment income, dividend income, interest income, tips, and alimony. Do not report untaxed income such as Supplemental Security Income, child support, or federal or state public assistance. Example: for items 8 and 11, as appropriate, if you are submitting a pay stub that indicates that your gross pay for the pay period is $800.99, report $800 in Item 8.

Provide one piece of documentation of each source of taxable income, such a pay stub, bank statement, or a social security earnings statement (see Section 7). Copies of the original documentation are acceptable. Documentation must be dated within 90 days of the date you signed this form. If you have multiple sources of income, provide documentation of your income from each source, but only report your primary source of income in Items 8 and 11, as appropriate.

8. Amount of your taxable income (that is reflected on the documentation you provide):

,

9. Frequency with which you receive the income reflected on the documentation that you provide:

Weekly Every Two Weeks Twice Per Month Monthly Annually

10.

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

If you are married and checked box 2, 3, or 4 in Section 2, you must provide documentation of your spouse’s income and complete items 11, 12, and 13; otherwise, skip to Section 4.

11. Amount of your spouse’s taxable income (that is reflected on the documentation you provide):

,

12. Frequency with which your spouse receives the income reflected on the documentation that you provide:

Weekly Every Two Weeks Twice Per Month Monthly Annually

13.

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

SECTION 4: CERTIFICATION AND SIGNATURE

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), documentation of my income for the purpose of determining my repayment amount under IBR or ICR Plan. I understand that (1) if I do not provide this information to the Department I will either not be allowed to repay my loan(s) under the IBR or ICR Plan or my monthly payment amount will be recalculated and no longer be based on my income; and (2) if I am married, my spouse’s income information, documentation, and signature are also required if I am repaying under the ICR Plan, if I am repaying under the IBR Plan and my spouse and I file a joint federal tax return, or if my spouse and I have a joint Direct Consolidation Loan.

Borrower Signature

Date (MM-DD-YYYY)

Spouse Signature (if required)

Date (MM-DD-YYYY)

Note: a spouse’s signature is required if you checked boxes 2, 3, or 4 in Section 2.

SECTION 5: INSTRUCTIONS

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

• You were not required to file a federal tax return for the most recently completed tax year;

• You do not have a copy of your most recently filed federal tax return and cannot provide other acceptable documentation of Adjusted Gross Income (AGI); or

• You have been notified by your loan servicer that alternative documentation of your income is required.

YOU MAY complete this form if you are repaying or are applying to repay your Direct Loans under the IBR or ICR Plan and:

• Your AGI, as reported on your most recently filed federal tax return, does not reasonably reflect your current income, due to, for example, the loss or change in employment by you or your spouse.

YOU ARE NOT REQUIRED to complete this form if you are repaying your Direct Loans under the IBR or ICR Plan and:

• Your AGI, as reported on your most recently filed federal tax return, reasonably reflects your current income.

In cases where alternative documentation of your income is used, the amount of your monthly payment under the IBR or ICR 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 your servicer that your AGI has changed significantly since you last submitted 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 or applying to repay your loans under the ICR Plan, (2) you are repaying or applying to repay your loans under the IBR Plan and you and your spouse file a joint federal tax return, or (3) you and your spouse have a joint Direct Consolidation Loan. If you need assistance, please call your Direct Loan servicer (see Section 6).

SECTION 6: WHERE TO SEND THIS COMPLETED FORM

Return the completed form and any required documentation to: (If no address is shown, return to your Direct Loan servicer.)

If you need help completing this form, call: (If no telephone number is shown, call your Direct Loan servicer.)

SECTION 7: 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 authorities for collecting the requested information from and about you are §421 et seq. and §451 et seq. of the Higher Education Act of 1965, as amended (20 U.S.C. 1071 et seq. and 20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Education Loan (FFEL) Program or 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 FFEL and/or Direct Loan Programs, 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) becomes delinquent or defaults. 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 statuses, 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 such collection displays a valid OMB control number 1845-0016. Public reporting burden for this collection of information is estimated to average 15 minutes (0.25 hours) per response, including the time for reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and completing and reviewing the information collection. Individuals are obligated to respond to this collection to obtain a benefit in accordance with 34 CFR 685.209 or 685.221. Send comments regarding the burden estimate(s) or any other aspect of this collection of information, including suggestions for reducing this burden to the U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC 20210-4537 or e-mail [email protected] and reference OMB Control Number 1845-0016. Note: Please do not return the completed form to this address.

If you have questions regarding the status of your individual submission of this form, contact your Direct Loan servicer (see Section 6).

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