Perkins Assignment Institutional Cert Form

Print Form
According to the Paperwork Reduction Act of 1995, no persons are required to respond to
collection information unless such collection displays a valid OMB control number. The valid
OMB control number for this information collection is 1845-0048. The time required to
complete this information collection is estimated to average 30 minutes per response, including
the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to U.S.
Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns
regarding the status of your individual submission of this form, write directly to Federal Student
Aid, U.S. Department of Education, Operations Services, Processing Division, Perkins Loan
Assignments, 50 Beale Street, Suite 8601, San Francisco, CA 94105.

OMB Number 1845-0048
Form Approved
Expiration Date: XXXXXXX

Federal Perkins Loan Program/NDSL
Assignment Form: Institutional Certification
The borrower(s) named on the attached manifest received Federal Perkins Loan Program, National Direct Student Loan Program, or National
Defense Student Loan Program loan(s) authorized under Title IV, Part E, of the Higher Education Act of 1965, as amended, or authorized under
Title II of the National Defense Education Act. The institution is assigning all rights and title under such note or agreement to the United States
Department of Education, without recompense as provided under Section 463(a)(5), 20 U.S.C. 1087cc.
SECTION A - INSTITUTIONAL INFORMATION
2. Serial Number

1. Name of Institution

3. Street Address of Institution

4. City

5. State

State

6. ZIP

SECTION B - CERTIFICATION
I understand that if I knowingly make a false statement or misrepresentation on this form in the course of assigning loans to the United States
Department of Education, I am subject to a fine of up to $10,000 or imprisonment of up to five (5) years or both under provisions of the United
States Criminal Code, 18 U.S.C. 1001.
7. Typed Name of Authorized Institutional Official

8. Telephone Number

9. Typed Title of Authorized Institutional Official

10. Alternate Contact Person

11. Signature of Authorized Institutional Official

12. Certification Date (MM/DD/YYYY)

SECTION C - MANIFEST
Instructions: Attach a manifest to this form listing the loans that are being assigned. The institution name and Serial Number must appear at
the top of each page of the manifest. The manifest must be in the following format:
Borrower's Name and
Social Security Number

Loan Type

Interest Rate

Total Amount Outstanding
(Section D, Item # 37)

Date of First
Disbursement

Under “Loan Type” indicate P for Perkins Loans, I for National Direct Student Loans, and E for National Defense Student Loans. If a borrower
received loans of different types and/or interest rates, the loans must be assigned as separate loans and listed on the manifest as separate loans,
regardless of how they were reported to NSLDS. NOTE: “Date of First Disbursement” for each loan listed on the manifest must match
the date of first disbursement initially reported to NSLDS. See Detailed Instructions.