False Certification Disqualifying Status

LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION
(DISQUALIFYING STATUS)

OMB No. 1845-0058
DRAFT FORM
Exp. Date XX/XX/XXXX

William D. Ford Federal Direct Loan (Direct Loan) Program
Federal Family Education Loan (FFEL) Program
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: BORROWER IDENTIFICATION
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: DISQUALIFYING STATUS INFORMATION
Carefully read the entire application before completing it. Complete Section 2 in its entirety.
1. You are applying for this loan discharge as a:
Student borrower - Skip to Item 4.
Parent PLUS borrower - Continue to Item 2. Unless
otherwise noted, "you" means the student you
borrowed the PLUS Loan for.
2. Student Name (Last, First, MI):

8. Indicate your disqualifying status by checking the
appropriate box(es) below. You must provide
documentation that shows you had the disqualifying
status when you received the loan you want
discharged.
Age
Physical condition
Mental condition

3. Student SSN:

Criminal record
Other (specify):

4. School Name:
5.

9. You must provide the state legal requirements for
employment that you could not meet when you
received the loan you want discharged. Provide a
citation to the specific state law or regulation below, or
attach a copy of the law or regulation to your
application.

School Address (street, city, state, zip code):

10. Before you received your loan, did the school ask you if
your disqualifying status existed?
Yes - Skip to Item 12.

6. Enter the dates that you attended the school:
First Date:

OR

Don't Know

No - Continue to Item 11.

Last Date:
7. Provide the name of the program of study that you
were enrolled in when you received the loan that you
want discharged:
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Don't Know - Continue to Item 11.

Borrower Name

Borrower SSN

SECTION 2: DISQUALIFYING STATUS INFORMATION (CONTINUED)
11. Did you tell the school about your disqualifying status
before you received your loan?
Yes

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

No
12. Have you (or the student) requested or received a
refund or payment from the closed school or any third
party (see Section 6) for any loan that you are
requesting be discharged?

16. Did we receive any money back (a refund) from the
school on your behalf?
Yes - Continue to Items 17-18.
No - Sign and date the form in Section 3. Submit the
application and documentation to address in
Section 7.

Yes - Continue to Item 13.
No - Skip to Item 16.
Don't Know - Skip to Item 16.

Don't Know - Sign and date the form in Section 3.
Submit the application and documentation to the
address in in Section 7.

13. Provide the name, address, and telephone number of
the organization you (or the student) made the claim
with:
Name:

17. What was the amount of the refund?

Address (street, city, state, zip code):
18. Explain why the money was refunded:
Telephone Number:
14. What is the amount and the status of the claim?
Amount:
Status

Sign and date the application in Section 3. Submit the
application and documentation to the address in Section 7.

SECTION 3: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION
I certify that:
• I have read and agree to the terms and conditions for loan discharge, as specified in Section 6.
• 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 school.
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

Borrower's Signature

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SECTION 4: 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.
Example: March 14, 2018 = 03-14-2018. If you need more space to answer any of the items, continue on separate sheets of
paper and attach them to this application. Indicate the number of the Items you are answering and include your name and
Social Security Number (SSN) on pages 2 and 3 of the application and all attached pages. Return the completed application
and documentation to the loan holder in Section 7.
SECTION 5: DEFINITIONS
The William D. Ford Federal Direct Loan (Direct Loan)
Program includes Federal Direct Stafford/Ford (Direct
Subsidized) Loans, Federal Direct Unsubsidized Stafford/
Ford (Direct Unsubsidized) Loans, Federal Direct PLUS
(Direct PLUS) Loans, and Federal Direct Consolidation
(Direct Consolidation) Loans.
The Federal Family Education Loan (FFEL) Program
includes Federal Stafford Loans (both subsidized and
unsubsidized), Federal Supplemental Loans for Students
(SLS), Federal PLUS Loans, and Federal Consolidation Loans.
The holder of your Direct Loan Program loans is the
Department. The holder of your FFEL Program loans may be
a lender, a guaranty agency, or the Department. The holder
of your Perkins Loans may be a school 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”, "we", or "us" on this form mean either
your loan holder or your servicer.
If your loan is discharged, this means that you (and any
endorser) are not required to repay the remaining portion of
the loan, and you will be reimbursed for any payments on
the loan that you made voluntarily or that we received
through forced collection (for example, through wage
garnishment or Treasury offset). For a consolidation loan,
only the portion that represents the original loans you
received and that are eligible for discharge will be
discharged.

The loan holder reports the discharge to all consumer
reporting agencies to which the holder previously reported
the status of the loan and requests the removal any adverse
credit history previously associated with the loan.
The student refers to the student the parent borrower
obtained a Direct PLUS Loan or Federal PLUS Loan for.
Program of study means the instructional program
leading to a degree or certificate you (or the student) were
enrolled in.
Origination and certification are steps in a school's
processing of a loan. In the Direct Loan Program, a loan is
originated when the school creates an electronic loan
origination record after determining that the borrower
meets all loan eligibility requirements. In the FFEL Program,
a loan is certified when the school signs a loan application
or submits an electronic loan record to the lender or
guaranty agency after determining that the borrower
meets all loan eligibility requirements.
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 6: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION
Only loans made on or after January 1, 1986 are
eligible for this type of discharge.
By signing this application, 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, or that supports any statement you made on
this application or in any accompanying documents.

By signing this application, you are agreeing to cooperate
with the Department or the Department's designee in any
enforcement action related to this application.
We may deny your application or revoke your discharge 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 representations you made on this application or
in any accompanying documents.

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SECTION 7: WHERE TO SEND THE COMPLETED APPLICATION
Return the completed application and any documentation to:
(If no address is shown, return to your loan holder.)

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

SECTION 8: 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. and §451 et seq. of the
Higher Education Act of 1965, as amended (20 U.S.C. 1071 et
seq. and 20 U.S.C. 1087a 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
Federal Family Education Loan (FFEL) Program or the
William D. Ford Federal Direct Loan (Direct 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 FFEL and/or Direct 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 caseby-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 it displays a
valid OMB control number. The valid OMB control number
for this information collection is 1845-0058. Public reporting
burden for this collection of information is estimated to
average 30 minutes per response, including time for
reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and
completing and reviewing the information collection. The
obligation to respond to this collection is required to obtain
or retain a benefit (34 CFR 682.402(e)(3), or 685.215(c)). If
you have comments or concerns regarding the status of
your individual submission of this form, contact your loan
holder directly.

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