Form 1 HRSA 504

APPLICATION FOR CONTRACT OF FEDERAL LOAN INSURANCE

Department of Health and Human Services

Health Resources and Services Administration

PUBLIC BURDEN STATEMENT

An agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. The OMB control number for this project is 0915‑0034. Public burden is estimated at 8 minutes for the lender/holder per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10‑29, Rockville, Maryland 20857.

You can use this form to apply to participate in the Health Education Assistance Loan (HEAL) Program.

INSTRUCTIONS

Item 1b. Enter your six digit code number, which was assigned to you by the HEAL Program. If you have not previously been assigned a code number, leave this item blank. If your institution has branch offices, they are covered by the approval of the application unless those offices maintain their own loan accounting systems. In those cases a separate application(s) is required.

Items 3 and 4. If your institution is an instrumentality of a State (State Loan Agency), you are not required to complete Items #3 and #4.

Item 5. Enter the regulatory (Federal or State) agency.

You must attach supporting documents to show that your institution is capable of complying with the HEAL Statute, regulations, and policy directives. In addition to other information you may wish to submit, you must submit the following:

If the applicant is a commercial institution, a copy of the latest Annual Report;

If the applicant is a lender for other Federal/State programs, a copy of your latest Call Report showing the loan activities (delinquency/default rates, etc.);

If the applicant is a State Agency, a copy of your latest State Agency reports submitted to the Department of Education showing loan activities (delinquency/default rates, etc.).

CONTACT INFORMATION

In the next column please provide the requested information of the officials who will serve as the points of contact to receive the following. (You must report any directory changes occurring during the application period to the HEAL Program.)

CODE NUMBER

Quarterly Interest Rate Announcements:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______­ (_______)_______________________

Quarterly Reports on HEAL Loans Outstanding:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______­ (_______)_______________________

Policy and Procedures Questions:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______­ (_______)_______________________

Loan and Disbursement Processing:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______­ (_______)_______________________

Claims Questions:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______­ (_______)_______________________

Entity serving as your Loan Servicer:

CONTACT NAME:________________________________

COMPANY NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______­ (_______)_______________________

Customer Service Contact Number(_____)__________

­­­­­­­­­­­­­­­­­­­­­­HRSA-504

Rev. 09/06

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH RESOURCES AND SERVICES ADMINISTRATION

ROCKVILLE, MARYLAND 20857

APPLICATION FOR CONTRACT

OF FEDERAL LOAN INSURANCE

(Authority: 42 U.S.C. 292‑292o)

FORM APPROVED

OMB NO. 0915‑0034

EXP. DATE 10/31/2012

DATE OF APPLICATION

PLEASE FORWARD ONE EXECUTED APPLICATION AND REQUIRED ATTACHMENTS TO:

DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF STUDENT LOANS AND SCHOLARSHIPS ‑ HEAL PROGRAM

PARKLAWN BUILDING, ROOM 9‑105

5600 FISHERS LANE

ROCKVILLE, MARYLAND 20857

We hereby apply for a contract under the provisions of Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 292‑292o) and the regulations of the Secretary issued there under. We submit this application for the period

_______________________________________to______________________________________

and the attached information, incorporated in and made a part hereof (see instructions).

1a. NAME (Exact corporate title) AND ADDRESS (Street, City, State and Zip Code)

1 b. CODE NUMBER

CODE NUMBER

2. TYPE OF INSTITUTION (Check applicable box)

 NATIONAL BANK  STATE SAVINGS AND LOAN  INSURANCE COMPANY

 STATE BANK (Member FDIC)  FEDERAL CREDIT UNION  PENSION FUND

 STATE BANK (Nonmember FDIC)  STATE CREDIT UNION  SCHOOL LENDER

 FEDERAL SAVINGS AND LOAN  MUTUAL SAVINGS BANK  OTHER (Specify)________________________

ITEMS 3 and 4 TO BE COMPLETED BY ALL APPLICANTS EXCEPT FOR ACADEMIC INSTITUTIONS OR STATE LOAN AGENCIES.

3. DATE ORGANIZED

4. INCORPORATED UNDER LAWS OF

5. WE ARE SUBJECT TO (Check applicable box)

 FEDERAL SUPERVISION  STATE SUPERVISION  OTHER

BY:

I agree to develop and follow written procedures for servicing and collection of HEAL loans. Although HEAL Policy 2004-1 no longer requires biennial audit be conducted as specified in Section 60.42(d), we strongly encourage you to conduct such an audit. I also agree to incorporate any of our servicing and collection procedures used for our other loans of comparable dollar value that are more stringent than those required by Sections 60.34 of the HEAL regulations.

In addition, I certify that neither this institution, nor any of its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency Sub-awardees (e.g., other corporations, partnerships, or other legal entities) have also provided the same certification to this institution.

SIGNATURE OF OFFICER

TYPED NAME AND TITLE OF OFFICER

DATE

WARNING: Any persons who knowingly makes a false statement or misrepresentation in a HEAL transaction, bribes, or attempts to bribe a Federal official, fraudulently obtains a HEAL Loan or comments any other illegal action in connection with a HEAL loan is subject to a fine or imprisonment under Federal statute.

FOR GOVERNMENT USE ONLY

 APPROVED

 DISAPPROVED

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HRSA-504

Rev. 09-06

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