Third Party Servicer Data Form

OMB # 1845-0130
Under Review
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?

Yes

No

Yes

No

If yes, please provide the names(s):

Has the company ever operated under a different name?
If yes, please provide the name(s):

3. When did the company/organization begin conducting business as a third party servicer on behalf of Title
IV, HEA institutions?
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?
6. What is the company’s/organization’s Dun & Bradstreet (DUNS) number?

N/A

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.

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:
City:
State and Zip: Select State
Telephone Number (including area code xxx-xxx-xxxx):
Fax Number (including area code xxx-xxx-xxxx):
E-Mail Address:

Suite/Apt:

8. Who is completing this form?
Name: (include prefix, such as Mr., Ms., Dr.)
Job Title:
Business Street Address:
City:
State and Zip: Select State
Telephone Number (including area code xxx-xxx-xxxx):
Fax Number (including area code xxx-xxx-xxxx):
E-Mail Address:

Suite/Apt:

9. Who is the highest ranking officer (CEO/COO/President) of this company/organization?
Name:
Job Title:
Business Street Address:
City:
State and Zip: Select State
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?

Suite/Apt:

Yes

No

If yes, list the electronic address (URL):

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.

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:
Business Street Address:
City:
State and Zip: Select State
Telephone Number (including area code xxx-xxx-xxxx):
Fax Number (including area code xxx-xxx-xxxx):
E-Mail Address:

12.

Suite/Apt:

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.)
Job Title:
Suite/Apt:
Street Address:
City:
State and Zip: Select State
Telephone Number (including area code xxx-xxx-xxxx):
Fax Number (including area code xxx-xxx-xxxx):
E-Mail Address:
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

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.

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, address,
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.)
Suite/Apt:
Street Address:
City:
State and Zip: Select State
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, address, 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.)
Suite/Apt:
Street Address:
City:
State and Zip: Select State
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
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.

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 the functions and/or processes performed:

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

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.

OPE ID

Name of College, University, Institution of
Higher Education

Service Start Date

Service End Date

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.

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:
Signature of President/CEO/COO:
(include prefix, such as Mr., Ms., Dr.)

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 1845-0130. 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]

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.

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

Additional Clients:

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.

SUBMIT