Discharge Application: Total and Permanent Disability

*** LOAN HOLDER USE ONLY ***

ORIGINAL RECEIPT DATE:

OMB No. 1845-0065 Form Approved Exp. Date xx/xx/xxxx	DISCHARGE APPLICATION: 30-DAY DRAFT 12/09/2011 TOTAL AND PERMANENT DISABILITY Federal Family Education Loan Program / Federal Perkins Loan Program / William D. Ford Federal Direct Loan Program / Teacher Education Assistance for College and Higher Education Grant Program WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents will be subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.
READ THIS FIRST: This is an application for a total and permanent disability discharge of your Federal Family Education Loan (FFEL) Program, Federal Perkins Loan (Perkins Loan) Program, and/or William D. Ford Federal Direct Loan (Direct Loan) Program loan(s), and/or your Teacher Education Assistance for College and Higher Education (TEACH) Grant Program service obligation. To qualify for this discharge (except for certain veterans as explained below), a physician must certify in Section 4 of this form that you are unable to engage in any substantial gainful activity (see definition in Section 5) by reason of a medically determinable physical or mental impairment that (1) can be expected to result in death; (2) has lasted for a continuous period of not less than 60 months; or (3) can be expected to last for a continuous period of not less than 60 months. This disability standard may differ from disability standards used by other federal agencies (for example, the Social Security Administration) or state agencies. Except as noted below for certain veterans, a disability determination by another federal or state agency does not establish your eligibility for this discharge. If you are a veteran, you will be considered totally and permanently disabled for purposes of this discharge if you provide documentation from the U.S. Department of Veterans Affairs (VA) showing that you have been determined to be unemployable due to a service-connected disability. If you provide this documentation, you are not required to have a physician complete Section 4 of this form or provide any additional documentation related to your disabling condition. You only need to complete Sections 1 and 3.
SECTION 1: APPLICANT IDENTIFICATION
				Please enter or correct the following information.
				SSN |____|____|____|-|____|____|-|____|____|____|____|
				Name
				Address
				City, State, Zip Code
				Telephone - Home ( )
				Telephone - Other ( )
				E-mail Address (Optional)
SECTION 2: INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION
Type or print in dark ink. Enter your name and Social Security Number at the top of page 2 (if not preprinted). Have a doctor of medicine or osteopathy complete and sign Section 4, unless you are a qualifying veteran (see the next bullet). If you are a veteran who has received a determination from the VA that you are unemployable due to a service-connected disability, attach documentation of this determination. You are not required to have a physician complete Section 4. If you do not have documentation showing that you are unemployable due to a service-connected disability and cannot obtain this documentation, you must have a physician complete Section 4. Sign and date the application in Section 3. A representative may sign on your behalf if you are unable to do so because of your disability. Make sure that Sections 3 and (if applicable) 4 include all requested information. Incomplete or inaccurate information may cause your application to be delayed or rejected. Send the completed application with any necessary attachments to the address shown below. If no address is shown, send the application and any attachments to your loan holder or, if you are applying for discharge of a TEACH Grant Program service obligation, to the U.S. Department of Education (the Department) at the address shown on correspondence you received related to your TEACH Grant. If you are applying for discharge of more than one loan and your loans are held by more than one loan holder, or if you are applying for discharge of both a TEACH Grant service obligation and one or more loans, you must submit a separate discharge application (original or copy) with any necessary attachments to each loan holder and, for TEACH Grants, to the Department. A “copy” means a photocopy of the original application completed by you (or your representative) and your physician. IMPORTANT: You must submit this application to your loan holder(s) and/or the Department within 90 days of the date of your physician’s signature in Section 4. See Section 3 for address and contact information. (NOTE TO VETERANS: This requirement does not apply if you are a veteran who provides the documentation described above under “READ THIS FIRST.”)
SECTION 3: APPLICANT’S DISCHARGE REQUEST, AUTHORIZATION, UNDERSTANDINGS, AND CERTIFICATIONS
Before signing, carefully read the entire application, including the instructions in Section 2 and other information on the following pages. I request that the Department discharge my FFEL, Perkins Loan, and/or Direct Loan program loan(s), and/or my TEACH Grant service obligation. I authorize any physician, hospital, or other institution having records about the disability that is the basis for my request for a discharge to make information from those records available to the holder(s) of my loan(s) and/or to the Department. I understand that (i) I must submit a separate discharge application to each holder of the loan(s) that I want to have discharged. If I am applying for discharge of both a TEACH Grant service obligation and one or more loans, I must submit a separate discharge application to each loan holder and, for TEACH Grants, to the Department. Unless I am a veteran who provides the documentation described above under “READ THIS FIRST,” I must submit a discharge application to each loan holder and/or the Department within 90 days of the date of my physician’s signature in Section 4. (ii) Unless I am a veteran who provides the documentation described above under “READ THIS FIRST,” I may be required to repay a discharged loan or satisfy a discharged TEACH Grant service obligation if I fail to meet certain requirements during a post-discharge monitoring period, as explained in Section 6. (iii) If I am a veteran, the certification by a physician on this form (if I am required to obtain such a certification) is only for the purposes of establishing my eligibility to receive a discharge of a FFEL Program loan, a Perkins Loan Program loan, a Direct Loan Program loan, and/or a TEACH Grant service obligation, and is not for purposes of determining my eligibility for, or the extent of my eligibility for, VA benefits. I certify that: (i) I have a total and permanent disability, as defined in Section 5. (ii) I have read and understand the information on the discharge process, the terms and conditions for discharge, and the eligibility requirements to receive future loans or TEACH Grants as explained in Sections 6 and 7.
Signature of Applicant or Applicant’s Representative			Date					Printed Name of Applicant’s Representative (if applicable)
Address of Applicant’s Representative (if applicable)								Representative’s Relationship to Applicant (if applicable)
Send the completed discharge application and any attachments to:							If you need help completing this form, call:

Applicant Name: _________________________________________ Applicant SSN: |__|__|__|-|__|__|-|__|__|__|__|

SECTION 4: PHYSICIAN’S CERTIFICATION

READ THIS FIRST: The applicant identified above is applying for a discharge of a federal student loan and/or a teaching service obligation for a federal grant on the basis that he or she has a total and permanent disability, as defined in Section 5 of this form. To qualify for a discharge, the applicant must be unable to engage in any substantial gainful activity (as defined in Section 5) by reason of a medically determinable physical or mental impairment that (1) can be expected to result in death; (2) has lasted for a continuous period of not less than 60 months; or (3) can be expected to last for a continuous period of not less than 60 months. This disability standard may be different from standards used under other programs in connection with occupational disability, or eligibility for social service or veterans benefits. A determination that the applicant is disabled by another federal agency (for example, the Social Security Administration) or a state agency does not establish the applicant’s eligibility for this loan discharge.

Instructions for Physician: Complete this form only if you are a doctor of medicine or osteopathy legally authorized to practice in a state, as defined in Section 5, and only if the applicant’s condition meets the definition of total and permanent disability in Section 5. Type or print in dark ink. All fields must be completed. If a field is not applicable, enter “N/A.” Your signature date must include month, day, and year (mm-dd-yyyy). Provide all requested information for Items 1, 2, and 3 below, and attach additional pages if necessary. Complete the physician’s certification at the bottom of this page. The applicant’s loan discharge application cannot be processed if the information requested in this section is missing. If you make any changes to the information you provide in this section, you must initial each change. Please return the completed form to the applicant or the applicant’s representative. The holder(s) of the applicant’s loan(s) (as defined in Section 5) or the U.S. Department of Education may contact you for additional information or documentation.

1. Medically Determinable Physical or Mental Impairment. Does the applicant have a medically determinable physical or mental impairment (as explained in Item 2 below) that (a) prevents the applicant from engaging in any substantial gainful activity, in any field of work, and (b) can be expected to result in death, or has lasted for a continuous period of not less than 60 months, or can be expected to last for a continuous period of not less than 60 months? Yes No Substantial gainful activity means a level of work performed for pay or profit that involves doing significant physical or mental activities, or a combination of both. If the applicant is able to engage in any substantial gainful activity, in any field of work, you must answer “No.” If the answer to Question 1 is No, do not complete this application.

2. Disabling Condition. Complete the following regarding the applicant’s disabling physical or mental impairment. Do not use abbreviations or insurance codes.

(a) Provide the diagnosis:

(b) Describe the severity of the disabling physical or mental impairment, including, if applicable, the phase of the disabling condition:

3. Limitations. Explain how the disabling condition prevents the applicant from engaging in substantial gainful activity in any field of work by responding to Items (a) through (e) below, as relevant to the applicant’s condition. Attach additional pages if more space is needed. In addition to what is required below, you may include any additional information that you believe would be helpful in understanding the applicant’s condition, such as medications used to treat the condition, surgical and non-surgical treatments for the condition, etc.

(a) Limitations on sitting, standing, walking, or lifting:

(b) Limitations on activities of daily living:

(c) Residual functionality:

(d) Social/behavioral limitations, if any:

(e) Current Global Assessment Function Score (for psychiatric conditions):

Physician’s Certification I certify that, in my best professional judgment, the applicant identified above is unable to engage in any substantial gainful activity in any field of work by reason of a medically determinable physical or mental impairment that (1) can be expected to result in death, (2) has lasted for a continuous period of not less than 60 months, or (3) can be expected to last for a continuous period of not less than 60 months. I understand that an applicant who is currently able to engage in any substantial gainful activity in any field of work does not have a total and permanent disability as defined on this form. I am a doctor of (check one) medicine osteopathy/osteopathic medicine. I am legally authorized to practice in a state, and have identified the state where I am licensed to practice and provided my professional license number below.

State Where Legally Authorized to Practice

Professional License Number (subject to verification through state records)

Physician’s Signature (a signature stamp is not acceptable)

Date (mm-dd-yyyy)

Printed Name of Physician (first name, middle initial, last name)

Address

City, State, Zip Code

( )

( )

Telephone

Fax

E-mail Address (Optional)

SECTION 5: DEFINITIONS

 If you have a total and permanent disability, this means that:

(1) You are unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that can be expected to result in death, that has lasted for a continuous period of not less than 60 months, or that can be expected to last for a continuous period of not less than 60 months, OR

(2) You are a veteran who has been determined by the VA to be unemployable due to a service-connected disability.

NOTE: This disability standard may differ from disability standards used by other federal agencies (for example, the Social Security Administration) or state agencies. Except in the case of certain veterans, a disability determination by another federal or state agency does not establish your eligibility for a discharge of your loan(s) and/or TEACH Grant service obligation due to a total and permanent disability.

 Substantial gainful activity means a level of work performed for pay or profit that involves doing significant physical or mental activities, or a combination of both.

 A discharge of a loan due to a total and permanent disability cancels your obligation (and, if applicable, an endorser’s obligation) to repay the remaining balance on your FFEL, Perkins Loan, and/or Direct Loan program loans. A discharge of a TEACH Grant service obligation cancels your obligation to complete the teaching service that you agreed to perform as a condition for receiving a TEACH Grant.

 The post-discharge monitoring period begins on the date the Department grants a discharge of your loan(s) or TEACH Grant service obligation and lasts for three years. If you fail to meet certain conditions at any time during or at the end of the post-discharge monitoring period, the Department will reinstate your obligation to repay your discharged loan(s) or complete your TEACH Grant service obligation. See Section 6 for more information.

 The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans (both subsidized and unsubsidized), Federal Supplemental Loans for Students (SLS), Federal PLUS Loans, and Federal Consolidation Loans.

 The Federal Perkins Loan (Perkins Loan) Program includes Federal Perkins Loans, National Direct Student Loans (NDSL), and National Defense Student Loans (Defense Loans).

 The William D. Ford Federal Direct Loan (Direct Loan) Program includes Federal Direct Stafford/Ford Loans (Direct Subsidized Loans), Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans), Federal Direct PLUS Loans (Direct PLUS Loans), and Federal Direct Consolidation Loans (Direct Consolidation Loans).

 The Teacher Education Assistance for College and Higher Education (TEACH) Grant Program provides grants to students who agree to teach full time for at least four years in high-need fields in low-income elementary or secondary schools as a condition for receiving the grant funds. If a TEACH Grant recipient does not complete the required teaching service within eight years after completing the program of study for which the TEACH Grant was received, the TEACH Grant funds are converted to a Direct Unsubsidized Loan that the grant recipient must repay in full, with interest, to the Department.

 The holder of your FFEL Program loan(s) may be a lender, a guaranty agency, or the Department. The holder of your Perkins Loan Program loan(s) may be a school you attended or the Department. The holder of your Direct Loan Program loan(s) is the Department. If you received a TEACH Grant, the Department holds your TEACH Grant Agreement to Serve.

 The term “state” as used on this application includes the 50 United States, the District of Columbia, American Samoa, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau.

SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (continues on next page)

NOTE: If you are applying for discharge of loans that are held by the Department, or are applying for discharge of a TEACH Grant service obligation, the discharge process begins with the review by the Department described below.

For veterans who have been determined by the VA to be unemployable due to a service-connected disability:

1. Review of discharge application by your loan holder. Your loan holder will review your completed discharge application and the required documentation you provide from the VA. If the documentation indicates that you are totally and permanently disabled in accordance with paragraph (2) of the definition of “total and permanent disability” in Section 5, your loan holder will refer your application and the accompanying documentation to the Department for further review. If the documentation from the VA does not indicate that you are totally and permanently disabled, you will be notified that you must resume payment of your loan(s). If the documentation from the VA does not indicate that you are totally and permanently disabled in accordance with paragraph (2) of the definition of “total and permanent disability,” but it indicates that you may be totally and permanently disabled in accordance with paragraph (1) of the definition, you will be notified that you may reapply for discharge under the process for other applicants, as described below. For FFEL Program loans held by a lender, both the lender and the guaranty agency will review your application and accompanying documentation before sending the application and documentation to the Department.

2. Review of discharge application by the Department. The Department will review the documentation from the VA to determine if you are totally and permanently disabled in accordance with paragraph (2) of the definition of “total and permanent disability” in Section 5.

3. Discharge. If the Department determines that you are totally and permanently disabled, you will be notified that your loan(s) and/or TEACH Grant service obligation has been discharged. The discharge will be reported to national consumer reporting agencies, and any loan payments received on or after the effective date of the determination by the VA that you are unemployable due to a service-connected disability will be refunded to the person who made the payments. If the Department determines that you are not totally and permanently disabled, you will be notified that you must resume repayment of your loan(s), or if you applied for discharge of a TEACH Grant service obligation, that you must comply with all terms and conditions of your TEACH Grant Agreement to Serve.

For all other applicants:

1. Review of discharge application by your loan holder. Your loan holder will review your completed discharge application and any accompanying documentation to determine whether you appear to be totally and permanently disabled in accordance with paragraph (1) of the definition of “total and permanent disability” in Section 5. If applicable, your loan holder may also contact your physician for additional information. For FFEL Program loans held by a lender, this determination will be made by both the lender and the guaranty agency. If the loan holder determines that you do not appear to be totally and permanently disabled, you will be notified of that decision. You must then resume payment of your loan(s). If your loan holder determines that you appear to be totally and permanently disabled, your loan(s) will be assigned to the Department. The Department will be your new loan holder.

2. Review of discharge application by the Department. The Department will review the physician’s certification in Section 4 and any accompanying documentation to determine if you are totally and permanently disabled in accordance with paragraph (1) of the definition of “total and permanent disability” in Section 5. The Department may also contact your physician for additional information, or may arrange for an additional review of your condition by an independent physician at the Department’s expense. Based on the results of this review, the Department will determine your eligibility for discharge.

3. Discharge. If the Department determines that you are totally and permanently disabled, you will be notified that a discharge has been granted, and that you will be subject to a post-discharge monitoring period for three years beginning on the discharge date. The notification of discharge will explain the terms and conditions under which the Department will reinstate your obligation to repay your discharged loan or complete your discharged TEACH Grant service obligation, as described in Item 4, below. The discharge will be reported to national consumer reporting agencies, and any loan payments that were received after the date the physician certified your discharge application will be returned to the person who made the payments.

If the Department determines that you are not totally and permanently disabled, you will be notified of that determination. You must then resume repayment of your loan(s), or if you applied for discharge of a TEACH Grant service obligation, you must comply with all terms and conditions of your TEACH Grant Agreement to Serve.

4. Post-discharge monitoring period. If you are granted a discharge, the Department will monitor your status during the 3-year post-discharge monitoring period that begins on the date the discharge is granted. The Department will reinstate your obligation to repay your discharged loan(s) and/or your obligation to complete your discharged TEACH Grant service obligation if, at any time during the post-discharge monitoring period, you:

• Receive annual earnings from employment that exceed the poverty line amount (see Note below) for a family of two in your state, regardless of your actual family size;

• Receive a new loan under the FFEL, Perkins Loan, or Direct Loan Program or a new TEACH Grant; or

• Fail to ensure that a loan or TEACH Grant disbursement was returned to the loan holder or (for a TEACH Grant) to the Department within 120 days of the disbursement date, in the case of a FFEL, Perkins, or Direct Loan program loan or a TEACH grant that was made before the discharge date, but was disbursed during the 3-year post-discharge monitoring period.

During the 3-year post-discharge monitoring period, you (or your representative) must:

• Promptly notify the Department if your annual earnings from employment exceed the poverty line amount for a family of two in your state (see Note below), regardless of your actual family size;

SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (continued from previous page)

• Promptly notify the Department of any changes in your address or telephone number; and

• If requested, provide the Department with documentation of your annual earnings from employment.

Note: The poverty line amounts are updated annually and may be obtained at http://aspe.hhs.gov/poverty. The Department will notify you of the current poverty line amounts during each year of the post-discharge monitoring period.

5. Reinstatement of obligation to repay discharged loans or complete discharged TEACH Grant service obligation. If you do not meet the requirements described above in Item 4 at any time during or at the end of the post-discharge monitoring period, the Department will reinstate your obligation to repay your discharged loan(s) and/or to complete your discharged TEACH Grant service obligation. If you received a discharge of your loan(s), this means that you will be responsible for repaying your loan(s) in accordance with the terms of your promissory note(s). However, you will not be required to pay interest on your loan(s) for the period from the date of the discharge until the date your repayment obligation was reinstated. The Department will continue to be your loan holder. If you received a discharge of your TEACH Grant service obligation, you will again be subject to the requirements of your TEACH Grant Agreement to Serve. If you do not meet the terms of that agreement and the TEACH Grant funds you received are converted to a Direct Unsubsidized Loan, you must repay that loan in full, and interest will be charged from the date(s) that the TEACH Grant funds were disbursed.

If your obligation to repay a loan or complete a TEACH Grant service obligation is reinstated, the Department will notify you of the reinstatement. This notification will include:

• The reason or reasons for the reinstatement;

• For loans, an explanation that the first payment due date following the reinstatement will be no earlier than 60 days following the notification of reinstatement; and

• Information on how you may contact the Department if you have questions about the reinstatement, or if you believe that your obligation to repay a loan or complete a TEACH Grant service obligation was reinstated based on incorrect information.

SECTION 7: ELIGIBILITY REQUIREMENTS TO RECEIVE FUTURE LOANS OR TEACH GRANTS

For veterans who receive a total and permanent disability discharge based on a determination by the VA that they are unemployable due to a service-connected disability:

If you are granted a discharge based on a determination that you are totally and permanently disabled in accordance with paragraph (2) of the definition of “total and permanent disability” in Section 5, you are not eligible to receive future loans under the FFEL, Perkins Loan, or Direct Loan programs or TEACH Grants unless:

• You obtain a certification from a physician that you are able to engage in substantial gainful activity; and

• You sign a statement acknowledging that the new loan or TEACH Grant service obligation cannot be discharged in the future on the basis of any injury or illness present at the time the new loan or TEACH Grant is made, unless your condition substantially deteriorates so that you are again totally and permanently disabled.

For all other individuals who receive a total and permanent disability discharge:

If you are granted a discharge based on a determination that you are totally and permanently disabled in accordance with paragraph (1) of the definition of “total and permanent disability” in Section 5, you are not eligible to receive future loans under the FFEL, Perkins Loan, or Direct Loan programs or TEACH Grants unless:

• You obtain a certification from a physician that you are able to engage in substantial gainful activity;

• You sign a statement acknowledging that the new loan or TEACH Grant service obligation cannot be discharged in the future on the basis of any injury or illness present at the time the new loan or TEACH Grant is made, unless your condition substantially deteriorates so that you are again totally and permanently disabled; and

• If you request a FFEL, Perkins Loan, or Direct Loan program loan or a new TEACH Grant within three years of the date that a previous loan or TEACH Grant was discharged, you resume payment on the previously discharged loan or acknowledge that you are once again subject to the terms of the TEACH Grant Agreement to Serve before receiving the new loan.

SECTION 8: 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., §451 et seq.,§461 et seq., and §420L et seq. of the Higher Education Act of 1965, as amended (the HEA) (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa et seq., and 20 U.S.C. 1070g 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 §31001(i)(1) of the Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)). Participating in the Federal Family Education Loan (FFEL) Program, the William D. Ford Federal Direct Loan (Direct Loan) Program, the Federal Perkins Loan (Perkins Loan) Program, and/or the Teacher Education Assistance for College and Higher Education (TEACH) Grant 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 FFEL, Direct Loan, and/or Perkins Loan program loan or a TEACH Grant, to receive a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) or a discharge of a TEACH Grant service obligation, to permit the servicing of your loan(s) or TEACH Grant(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. 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.

For a loan or for a TEACH Grant that has not been converted to a Direct Unsubsidized Loan, the routine uses of the information that we collect about you include, but are not limited to, its disclosure to federal, state, or local agencies, to institutions of higher education, and to third party servicers to determine your eligibility to receive a loan or a TEACH Grant, to investigate possible fraud, and to verify compliance with federal student financial aid program regulations.

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.

For a loan, including a TEACH Grant that has been converted to a Direct Unsubsidized Loan, the routine uses of this information also 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 creditors, to financial and educational institutions, and to guaranty agencies to verify your identity, to determine your program eligibility and benefits, to permit making, servicing, assigning, collecting, adjusting, or discharging 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, to locate you if you become delinquent in your loan payments or if you default, or to verify whether your debt qualifies for discharge or cancellation. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state or local 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 status, 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.

Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 0.5 hours (30 minutes) 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 674.61(b)(2) or (c)(2), 34 CFR 682.402(c)(2) or (c)(8), 34 CFR 685.213(b)(1) or (c)(1), and 34 CFR 686.42(b)(1). 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 1845-0065. Note: Please do not return the completed Discharge Application to this address.

If you have comments or concerns regarding the status of your individual submission of this form, contact your loan holder (see Section 3).

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