513 Form

Health Education Assistance Loan (HEAL) Program: Lender's Application for Insurance Claim Form and Request for Collection Assistance Form

Final of HEAL form 513 6 19 2014

Health Education Assistance Loan (HEAL) Program: Lender's Application for Insurance Claim Form and Request for Collection Assistance Form

OMB: 1845-0127

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FORM APPROVED

OMB No. 1845-0127

EXP DATE:



U. S. DEPARTMENT OF EDUCATION

Federal Student Aid


DATE OF REQUEST



FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

REQUEST FOR COLLECTION ASSISTANCE

(42 U.S.C. 292-2920) and the Consolidated Appropriation Act, 2014




PRA Burden Statement: 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 1845-0127. Public reporting burden for this collection of information is estimated to average 10 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 obtain or retain benefit (Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriations Act, 2014). If you have comment or concerns regarding the status of your individual submission of this form, please contact the HEAL Program, U.S. Department of Education, 830 First Street NE, Washington, DC, 20202 directly. [Note: Please do not return the completed form to this address.]


FROM (Name of Lender)

LENDER

IDENTIFICATION

SERVICER IDENTIFICATION

TO: Department of Education,

Program Support Center (PSC)

12501 Ardennes Ave., Suite 100

Rockville, MD 20857


STREET ADDRESS

CITY AND STATE

ZIP CODE

NAME AND TITLE

TELEPHONE

AREA CODE

NUMBER

We request your assistance on the Delinquent Borrower below:

NAME OF BORROWER (Last, First, MI)

DISCIPLINE



SOCIAL SECURITY NUMBER



TELEPHONE

AREA CODE

NUMBER


MAILING ADDRESS

CITY

STATE

ZIP CODE



LAST SCHOOL ATTENDED

SCHOOL IDENTIFICATION

SCHOOL DATE

Graduation____________________________

Withdrawal____________________________

NAME OF NEAREST RELATIVE

ADDRESS

CITY


STATE

ZIP CODE

NAME OF PARENT OR GUARDIAN

ADDRESS

CITY


STATE

ZIP CODE

ORIGINAL PRINCIPAL LOAN AMOUNT



UNPAID PRINCIPAL AND INTEREST

PERCENT INTEREST

NUMBER OF PAYMENTS MADE TO DATE

REASON FOR THIS REQUEST (Check one)

1a. STUDENT IS DELINQUENT ON MONTHLY PAYMENTS 1b. REFINANCED LOAN Yes No


NUMBER OF PAYMENTS


AMOUNT DUE PER MONTH


$

2. SKIP

3. OTHER (Explain)

WARNING: Any person who knowingly makes a false statement or misrepresentations in a HEAL loan transaction, bribes or attempts to bribe a Federal official, fraudulently obtains a HEAL loan, or commits any other illegal action in connection with a HEAL loan, is subject to possible fine(s) and imprisonment under Federal statute.

HEAL-513

File Typeapplication/msword
File TitleDEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED:
AuthorHrsa
Last Modified ByBeth Grebeldinger
File Modified2014-06-19
File Created2014-06-19

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