False Certification Unauthorized Signature

LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION
(UNAUTHORIZED SIGNATURE/PAYMENT)

OMB No. 1845-0058
Form Approved
Exp. Date 9/30/2020

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: UNAUTHORIZED SIGNATURE/PAYMENT INFORMATION
Do not use this application for allegations of identity theft. If you believe that your identity has been stolen, contact
your loan holder. Carefully read the entire application before completing it. Complete Section 2 in its entirety.
1. You are applying for this loan discharge as a:
8. Did you (or the student) ever receive any money from
the school, or did the school ever reduce the amount of
Student borrower - Skip to Item 4.
money that you owed to the school?
Parent PLUS borrower - Continue to Item 2. If a
Yes - Continue to Item 9.
question includes "(or the student)", answer as it
No - Skip to Item 11.
applies to the student you borrowed the loan for.
Don't Know - Skip to Item 11.
2. Student Name (Last, First, MI):
9. On what date did the school return money or reduce
the amount owed?
3. Student SSN:
4. School Name:

10. By what amount did the school return money or
reduce the amount owed?

5.

11. How did you pay tuition and fees at the school?

School Address (Street, City, State, Zip Code):

6. Dates that you (or the student) attended the school:
First Date:
Last Date:

OR

Never Attended
Don't Know

7. Which documents were signed without your
authorization?
Loan check
Loan application or promissory note
Master check or electronic funds transfer
authorization

12. Provide the name and position of the school employee
or other person associated with the school who signed
your name on the documents identified in Item 7.
Name:
Position:
OR

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Don't Know.

Borrower Name

Borrower SSN

SECTION 2: UNAUTHORIZED SIGNATURE/PAYMENT INFORMATION (CONTINUED)
13. Explain how the person identified in Item 12 signed
your name to the documents identified in Item 7:

16. What is the amount and the status of the claim?
Amount:
Status:
17. What was the amount of any payment received? If
none, write "none".
18. Did the school refund any money on your behalf?

14. Have you (or the student) requested or received a
refund or payment from the school or any third party
(see Section 5) for any loan that you are requesting be
discharged?
Yes - Continue to Item 15.
No - Skip to Item 18.
Don't Know - Skip to Item 18.
15. Provide the name, address, and telephone number of
the organization you requested or received a payment
from:

Yes - Continue to Item 19.
No - Sign and date the application in Section 3, then
send it with documentation of your signature to the
address in Section 7.
Don't Know - Sign and date the application in
Section 3, then send it with documentation of your
signature to the address in Section 7.
19. What was the amount of the refund?
20. Explain why the money was refunded:

Name:
Address (Street, City, State, Zip Code):

Telephone Number:
Documentation of your signature is required. You must attach documents containing four other samples of your
signature. At least two of these samples must show that your signatures were made within one year (before or after) of the
authorized signature or payment. Examples of documents include cancelled checks, tax returns, and driver's licenses. If you
do not provide these samples, you cannot be considered for a loan discharge. Continue to Section 3.
SECTION 3: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION
I certify that:
• I am applying for a discharge of my loans because the documents identified in Section 2, Item 7 were not signed or
authorized by me.
• I did not sign any of the documents I checked in Section 2, Item 7.
• 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 application and in any accompanying
documentation is true and accurate to the best of my knowledge and belief.
By signing this application, 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 APPLICATION
When completing this application, 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) at the top of page 2 and on all attached pages. Return the completed application
and documentation to the address shown 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” on this form mean either your loan holder
or your servicer.
Unauthorized signature means that the school, without
the borrower's authorization, signed the borrower's name
on the loan application or promissory note.

Unauthorized payment means that the school, without
the borrower's authorization, endorsed the borrower's loan
check or signed the borrower's authorization for electronic
funds transfer or master check, and did not give the loan
proceeds to the borrower or apply the loan proceeds to
charges owed by the student to the school.
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 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 of 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.
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.
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.)

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.
Your 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 representations you
made on this application or in any accompanying
documents.
If you need help completing this application, call:
(If no telephone number is shown, call your loan holder.)

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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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