Loan Discharge Application FORG

LOAN DISCHARGE APPLICATION: FORGERY

OMB No. 1845-XXXX
DRAFT FORM
Exp. Date XX/XX/XXXX

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan) Program
FFEL Program and Perkins Loan Program: You can use this form to apply for discharge of a FFEL Program
or Perkins Loan Program loan only if the loan is held by the U.S. Department of Education.
FORG
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on
any accompanying document is subject to penalties that may include fines, imprisonment, or both, under
the U.S. Criminal Code and 20 U.S.C. 1097.
SECTION 1: APPLICANT INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
State

City

Zip Code

Telephone - Primary
Telephone - Alternate
Email (Optional)
SECTION 2: DECLARATIONS
1. Below, list all loans you want discharged. List only
loans held by the U.S. Department of Education (the
Department). To find information about your loans,
visit StudentAid.gov/login or call 800-4-FED-AID.
Attach additional pages, if necessary.
Amount

Year Rec'd

4. Did you sign a promissory note, in ink or electronically,
for the loans that you want discharged?
Yes - You are not eligible for this type of discharge.
No.
5. Do you believe the person who borrowed the loans
you want discharged was an employee or affiliate of
the school that originated or certified the loans?
Yes - Complete the Loan Discharge Application for
False Certification based on Unauthorized
Signature or Payment instead of this form.
No.

School

Don't Know.
2. Did you intend to borrow the loans that you want
discharged?
Yes - You are not eligible for this type of discharge.
No.
3. Did you (or the student), receive a refund in cash,
check, or electronic funds transfer from the loans,
were the loans applied to your (or the student's)
account at a school that you attended, or did you (or
the student) benefit from the loans in any other way?
Yes.

6. Have you (or the student) attended postsecondary
school?
Yes.
No.
7. If you (or the student) attended a postsecondary
school, provide the names, dates of attendance, and
whether the program was an online program:
School

Explain how you benefited from the loans you
want discharged.

No.
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Dates

Online

Applicant Name

Applicant SSN

SECTION 2: DECLARATIONS (CONTINUED)
8. How did you (or the student) pay for the costs of
attendance, such as tuition and fees, at the school
listed in Item 7? Attach documentation (for example,
from the school’s financial records such as receipts
from the school, negotiated personal checks, etc.) to
show how you paid for the costs of attendance.

13. Which personal information was used without your
permission? Check any that apply.
Name
Social Security Number
Date of Birth
Address
Telephone Number
Signature
Other (identify):
14. On which documents was your personal information
used without your permission? Check any that apply.
Loan check
Loan application or promissory note

9. Provide your address and dates of residence from the
period of time when the loans you want discharged
were originated or certified:
Address

Master check or electronic funds transfer
authorization
Other (identify):

Dates of Residence

Don't Know.
15. How were the documents indicated in Item 14 signed?
By hand
Using an electronic process
Don't know
16. What documentation are you providing to support
your claim?
Samples of my signature - We require that you
provide four signature samples that appear on
actual documents that you signed. Two of these
samples must be dated one year before or after
the date the disputed document was signed.
Examples of documents include cancelled checks,
tax returns, Driver's License, etc.
A court verdict or judgment that determined I was
the victim of the crime of identity theft or forgery
and a copy of information or the indictment that
the verdict or judgment was based on
A government identification card, such as your
Driver’s License, state ID card, passport, or Social
Security Card
A statement from a handwriting expert

10. Was any of your information in your loan documents
for the loans you want discharged incorrect?
Yes - Continue to Item 11.
No- Skip to Item 12.
Don't Know - Skip to Item 12.
11. Which personal information was incorrect? Check any
that apply and attach documentation to show each
piece of correct information.
Name
Social Security Number
Date of Birth
Address
Names and Addresses of References
Other (identify):
12. Did you give anyone permission to use your personal
information to borrow the loans you want discharged?
Yes - Skip to Item 16.
No- Continue to Item 13.
Don't Know - Continue to Item 13.

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Proof of your residency from the time the loans
were made, such as a lease or utility bill
A complete Identity Theft Victim's Complaint and
Affidavit form provided by the Federal Trade
Commission
Other (identify):

Applicant Name

Applicant SSN

SECTION 2: DECLARATIONS (CONTINUED)
17. When did you first discover that someone forged
your name on loan documents?
18. When and with whom did you first seek to resolve the
forgery? Attach documentation such as copies of
letters or emails from prior loan holders discussing
your forgery allegation.
Person/Entity

21. If more than three months elapsed between the date
you first discovered that someone forged your
signature on loan documents and the date you filed
a police report, please explain your delay in filing the
report.

Dates of Contact

22. Do you know the name of the individual or
organization who signed your name, in ink or
electronically, without your permission?
Yes - Continue to Item 23.
No- Skip to Item 24.
19. If more than three months elapsed between the date
you first discovered that someone forged your
signature on loan documents, and the date you first
contacted the loan holder or another entity to allege
forgery, please explain your delay in attempting to
resolve this matter.

23. Provide the following information about the person or
organization who you allege forged your name on
loan documents:
Name
Organization
Address
City, State, Zip
Phone

20. Did you file a police report or other official complaint?

24. Did anyone other than you have access to the pieces
of personal information that were used without your
permission?
Yes - Continue to Item 25.

Yes, and will provide a copy. Continue to Item 23.

No- Skip to Item 26.

Yes, but cannot provide a copy.

Don't Know - Skip to Item 26.

Explain why you cannot provide a copy and then
continue to Item 21.

25. Explain who has or had access to your personal
information, their relationship to you, to what
information they have or had access, and their
contact information:

No - Skip to Item 22.

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Applicant Name

Applicant SSN

SECTION 2: DECLARATIONS (CONTINUED)
26. Did you make any claim with, or receive any payment
from, the school that originated or certified the loan
or any third party (see Section 5) in connection with
your claim?
Yes - Continue to Item 27.

29. What was the amount of any payment received? If
none, write "none".

30. Did the holder of your loan receive any money back (a
refund) from the school on your behalf?
Yes - Continue to Item 31.

No- Skip to Item 30.
Don't Know - Skip to Item 30.
27. Provide the following about the party with whom the
claim was made or from whom payment was received:
Name
Address

No- Skip to Item 33.
Don't Know - Skip to Item 33.
31. What was the amount of the refund?

City, State, Zip
Phone

32. Explain why the money was refunded:

28. What is the amount and status of the claim?
Amount
Status
33. Provide any other information or documentation you believe would be helpful in understanding the circumstances
surrounding your application. For example, if you identified an individual or organization in Item 23, explain why you
believe that the individual or organization used your personal information without permission. Explain how you learned
about the incident or how you believe the individual or organization used your information to secure the loans. Attach
additional pages, if needed.

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Applicant Name

Applicant SSN

SECTION 3: DOCUMENTATION
Documentation is required for your application to be processed:
• Documentation of each source of identification that you identified in Item 11 must be provided.
• Documentation of each source of evidence that you identified in Item 16 must be provided.
• Documentation of your signature is required if you indicated that one or more of your loan documents were signed
by hand in Item 16. At least two of these samples must show that your signature was more one year before or one
year after the date of the alleged forgery. Examples of documents include cancelled checks, tax returns, and driver's
licenses.
• Provide documentation of the date and people/entities that you identified in Item 18.
• Provide documentation of how you (or the student) paid for the cost of attendance, such as tuition and fees, at
the school, if you (or the student) attended a postsecondary school.
SECTION 4: APPLICANT CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION
I certify that:
1. I am applying for a discharge of Direct Loan Program, FFEL Program, or Perkins Loan Program loans held by the
Department that were borrowed in my name as the result of forgery.
2. I have read and agree to the terms and conditions for loan discharge, as specified in Section 7.
3. Under penalty of perjury, all of the information I have provided on this form and in any accompanying
documentation is true and accurate to the best of my knowledge and belief.
By signing this form I assign and transfer to the U.S. Department of Education (the Department) any right I have to a
refund on the amount discharged from the school and/or from any owners, affiliates, or assignees of the school, and from any
third party that pays claims for a refund because of the actions of the party who committed the forgery.
I authorize the organization I submit this request to and its agents to contact me regarding my request or my loans at the
cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or
prerecorded voice or text messages.

Date

Applicant's Signature

SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM
When completing this form, type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only numbers.
Examples, March 14, 2017 = 03-14-2017. If you need more space to answer any of the items, continue on separate sheets of
paper and attach them to this form. Indicate the number of the Item you are answering and include your name and Social
Security Number on all attached pages. Return the completed form any attachments to the address shown in Section 8.
SECTION 6: DEFINITIONS
The William D. Ford Federal Direct Loan (Direct
Loan) Program includes Direct Subsidized Loans,
Direct Unsubsidized Loans, Direct PLUS Loans, and
Direct Consolidation Loans.
The Federal Family Education Loan (FFEL)
Program includes Federal Stafford Loans (both
subsidized and unsubsidized), Federal PLUS Loans,
Federal Consolidation Loans, and Federal Supplemental
Loans for Students (SLS).

The Federal Perkins Loan (Perkins Loan) Program
includes Federal Perkins Loans, National Direct Student
Loans (NDSL), and National Defense Student Loans (Defense
Loans).
The holder of your Direct Loans is the Department. The
holder of your FFEL Program loans may be a lender,
guaranty agency, secondary market, or the Department. The
holder of your Perkins Loans is an institution of higher
education or the Department. Your loan holder may use a
servicer to handle billing and other communications related
to your loans. References to “your loan holder” on this form
mean either your loan holder or your servicer.
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SECTION 6: DEFINITIONS (CONTINUED)
Loan discharge due to forgery on a loan application
or promissory note cancels your obligation (and any
endorser's obligation, if applicable) to repay the
remaining portion of a Direct Loan, FFEL Program, or
Perkins Program loan, and qualifies you for
reimbursement of any amounts paid voluntarily or
through forced collection on the loan. For
consolidation loans, only the amount of the underlying
loans associated with the document that was signed
without your consent will be considered for discharge.
The loan holder requests the removal of any credit
history associated with the loan.

Third party refers to any entity that may provide
reimbursement for a refund owed by the school, such as a
State or other entity offering a tuition recovery program.

SECTION 7: TERMS AND CONDITIONS FOR LOAN DISCHARGE
By signing this form, you are agreeing to provide,
upon request, testimony, a sworn statement, or other
documentation reasonably available to you that
demonstrates to the satisfaction of the Department or
its designee that you meet the qualifications for loan
discharge due to forgery, or that supports any
representation that you made on this form or any
accompanying documents.

By signing this form, you are agreeing to cooperate with
the Department or the Department's designee in any
enforcement action related to this form.
This application may be denied, or your discharge may
be revoked, if you fail to provide testimony, a sworn
statement, or documentation upon request, or if you
provide testimony, a sworn statement, or documentation
that does not support the material representation that you
have made on this form or on any accompanying
documents.

SECTION 8: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to:
(If no address is shown, return to your loan holder.)

If you need help completing this form, call:
(If no telephone number is shown, call your loan holder.)

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SECTION 9: 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., or §461 of the Higher Education Act of 1965, as
amended (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., or
20 U.S.C. 1087aa 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 31 U.S.C. 7701(b). Participating in the William D. Ford
Federal Direct Loan (Direct Loan) Program, Federal Family
Education Loan (FFEL) Program, or Federal Perkins Loan
(Perkins Loan) 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 loan
or a benefit on a loan (such as a deferment, forbearance,
discharge, or forgiveness) under the Direct Loan, FFEL, or
Federal Perkins Loan Programs, to permit the servicing of
your loans, and, if it becomes necessary, to locate you and
to collect and report on your loans if your loans become
delinquent or 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. The routine uses of
this information 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 consumer reporting agencies, to
financial and educational institutions, and to guaranty
agencies in order to verify your identity, to determine your
eligibility to receive a loan or a benefit on a loan, to permit
the servicing or collection of your loans, to enforce the
terms of the loans, to investigate possible fraud and to verify
compliance with federal student financial aid program
regulations, or to locate you if you become delinquent in
your loan payments or if you default. To provide default rate
calculations, disclosures may be made to guaranty agencies,
to financial and educational institutions, or to state
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 statuses, 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.
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.
Paperwork Reduction Notice. 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[####]. Public reporting burden for this collection of
information is estimated to average 60 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 a benefit in accordance with
34 CFR 682.402 or 685.215. If you have comments or
concerns regarding the status of your individual submission
of this form, please contact your loan holder directly (see
Section 9.

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