Third Party Servicer Data Form

OMB #

Form Approved

Exp. Date: XX/XX/XXXX

Third Party Servicer Data Form

1. What is the legal name of this company/organization?      

2. Does the company/organization have another name such as a trade name or a

d/b/a name, under which the company conducts business?

If yes, please provide the names(s):

     

     

     

Yes

No

3. When did the company/organization begin conducting business as a third party servicer on behalf of Title

IV, HEA institutions? Click here to enter a date.

4. What name does the company/organization utilize to file its required annual compliance audit?

     

5. What is the company’s/organization’s fiscal year end date? Click here to enter a date.

6. What is the company’s/organization’s Dun & Bradstreet (DUNS) number?       N/A

7. Who are the owner/owners of this company/organization? If you need more space, please use additional

space provided on last page of form or attach an additional sheet and include the following for each owner:

Name:      

Job Title:      

Business Street Address:       Suite/Apt:      

City:      

State and Zip:            

Telephone Number (including area code xxx-xxx-xxxx):      

Fax Number (including area code xxx-xxx-xxxx):      

E-Mail Address:      

8. Who is completing this form?

Name: (include prefix, such as Mr., Ms., Dr.)      

Job Title:      

Telephone Number: (including area code xxx-xxx-xxxx)      

E-Mail Address:      

9. Who is the highest ranking officer (CEO/COO/President) of this company/organization?

Name:      

Job Title:      

Business Street Address:       Suite/Apt:      

City:      

State and Zip:            

Telephone Number: (including area code xxx-xxx-xxxx)      

Fax Number: (including area code xxx-xxx-xxxx)      

E-Mail Address:      

10. Does this company/organization have a web site (or home page) on the

Internet?

If yes, list the electronic address (URL):      

Yes

No

11. Whom should we contact at this company/organization should we have questions regarding information on

this form or need to respond to an institutional inquiry?

Name: (include prefix, such as Mr., Ms., Dr.)      

Job Title:      

Telephone Number: (including area code xxx-xxx-xxxx)      

Fax Number: (including area code xxx-xxx-xxxx)      

E-Mail Address:      

12. Check here if this company/organization maintains more than one physical location (mailing address,

processing center, etc.) and provide the primary contact person, address, and phone number for each

location occupied. If you need more space, please use additional space provided on last page of form or

attach an additional sheet and include the following for each entity:

Name: (primary contact person, include specific prefix, such as Mr., Ms., Dr.)      

Street Address:       Suite/Apt:      

City:      

State and Zip:            

Purpose of Location: (mailing address, processing center, etc.)      

13. Identify the ownership structure of this company/organization:

For Profit

Corporation – Publicly Traded

Corporation – Not Publicly Traded

Partnership

Sole Proprietorship

Not for Profit

State Owned Organization

State Affiliated Organization

Private, Not For Profit Organization

14. Check here if this company/organization owns or is owned by an eligible institution of Higher

Education (regardless of percentage) and provide the name of the entity, primary contact person, phone

number and e-mail below. If you need more space, please use additional space provided on last page of

form or attach an additional sheet and include the following for each entity:

Institution/Organization Name:      

Name: (primary contact’s name, include prefix, such as Mr., Ms., Dr.)      

Telephone Number: (including area code xxx-xxx-xxxx)      

Fax Number: (including area code xxx-xxx-xxxx)      

E-Mail Address:      

Description of Relationship with the entity listed above:      

15. Check here if this company/organization owns or is owned by another company/organization

(regardless of percentage) and provide the name of the entity, primary contact person, phone

number, and e-mail below. If you need more space, please use additional space provided on last page of

form or attach an additional sheet and include the following for each entity:

Company/Corporation/Organization Name:      

Name: (primary contact’s name, include prefix, such as Mr., Ms., Dr.)      

Telephone Number: (including area code xxx-xxx-xxxx)      

Fax Number: (including area code xxx-xxx-xxxx)      

E-Mail Address:      

Description of Relationship with the entity listed above:      

16. Please indicate the Title IV, HEA services this company/organization performs on behalf of its clients:

Process student financial aid applications, including FAFSA or Pre-FAFSA completion services

performed on behalf of an eligible institution

Collect, review, and/or maintain supporting documentation required to process Title IV funds

Determine student eligibility and related activities (R2T4, SAP, Verification, Professional Judgment,

Dependency Override, etc.)

Award, certify, originate, and/or disburse Title IV funds

Delivery of Title IV credit balance refunds to students or parents (via cash, check, ACH, debit card, or

other means)

Prepare and/or certify request for advance or reimbursement funding

Fiscal reconciliation of Title IV, HEA program accounts

Provide entrance and exit loan counseling, including in person, by mail, or electronically

Federal Perkins Loan servicing

Federal Perkins Loan collections

Financial aid counseling, including assistance provided to students or parents in person, over the phone,

or by any electronic means, including operation of call centers

Perform default prevention management functions for Direct Loan, FFEL, and/or Perkins Loan

programs, including cohort default analysis, enhanced loan counseling, delinquency assistance,

development/implementation of a default management plan, and/or other default prevention outreach

activities

Preparation/dissemination of required consumer information disclosures, including general, campus

crime, drug and alcohol prevention, graduation rates, placement rates and gainful employment

disclosures

Preparation and or submission of required reports including enrollment reporting to NSLDS, IPEDS,

Campus Crime and Security, and FISAP reporting

Financial aid consulting, including financial aid staffing, interim management, processing support,

and/or development and maintenance of written policies and procedures

Other, please describe:      

17. Provide the names and OPE ID numbers for each client for who this company/organization contracts with

to perform any aspect of the institution’s participation under the Title IV, HEA programs. If you need more

space, please use additional space provided on last page of form or attach an additional sheet and include

the following for each client:

OPE ID

Name of College, University, Institution of Higher Education

Service Start Date

Service End Date

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

OPE ID

Name of College, University, Institution of Higher Education

Service Start Date

Service End Date

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

I hereby certify that, to the best of my knowledge and belief, all information in this document is true and correct. I understand that if my company/organization provides false or misleading information, the Department considers this to be a breach of the fiduciary standard of conduct and may terminate the servicer’s eligibility to contract with any institution to administer any aspect of an institution’s participation in the Title IV, HEA programs. I also understand that I may be subject to a fine of not more than $25,000 or imprisonment of not more than five years, or both, for misinformation that is material to receipt and stewardship of federal student financial aid funds.

Signature of individual completing this form:

Date: Click here to enter a date.

Signature of President/CEO/COO:

(include prefix, such as Mr., Ms., Dr.)

Date: Click here to enter a date.

Please attach a copy of this company’s organizational chart with employee names and titles of those individuals who serve in a managerial or supervisory role and return this form to:

Third Party Servicer Oversight Group

U.S. Department of Education

Kansas City School Participation Division

1010 Walnut Street; Suite 336

Kansas City, MO 64106

(816) 268-0543

[email protected]

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. The valid OMB control number for this information collection is 1845-XXXX. Public reporting burden for this collection of information is estimated to average 75 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain the benefit to contract with eligible institutions pursuant to 34 C.F.R. § 668.25. If you have comments or concerns regarding the status of your individual submission of this form, please contact the Third Party Servicer Oversight Group directly at (816) 268-0543 or [email protected]

Additional space for questions:

7.      

12.      

14.      

15.      

17.

OPE ID	Name of College, University, Institution of Higher Education	Service Start Date	Service End Date
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

Other:      

For purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non-profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs.