HEAL Form 504 Contract for Federal Loan Insurance

APPLICATION FOR CONTRACT OF FEDERAL LOAN INSURANCE

Department of Education Federal Student Aid

PAPERWORK REDUCTION ACT 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 1845-0128. Public reporting burden for this collection of information is estimated to average 8 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 Appropriation Act, 2014). If you have comments 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.]

You can use this form to apply to participate in the Health Education Assistance Loan (HEAL) Program.

INSTRUCTIONS

Item 1b. Enter your six digit code number, which was assigned to you by the HEAL Program. If you have not previously been assigned a code number, leave this item blank. If your institution has branch offices, they are covered by the approval of the application unless those offices

• Quarterly Interest Rate Announcements:

CONTACT NAME:_ _ ADDRESS:

_

EMAIL ADDRESS _ TELEPHONE NO. ( )_ _

FAX NO. ( )_ _

• Quarterly Reports on HEAL Loans Outstanding:

CONTACT NAME:_ _ ADDRESS:

_

EMAIL ADDRESS _ TELEPHONE NO. ( )_ _

FAX NO. ( )_ _

• Policy and Procedures Questions:

CONTACT NAME:_ _ ADDRESS:

_

EMAIL ADDRESS _ TELEPHONE NO. ( )_ _

FAX NO. ( )_ _

• Loan and Disbursement Processing:

CONTACT NAME:_ _ ADDRESS:

^{maintain their own loan accounting systems. In those cases a separate} _

application(s) is required.

Items 3 and 4. If your institution is an instrumentality of a State (State Loan Agency), you are not required to complete Items #3 and #4.

Item 5. Enter the regulatory (Federal or State) agency.

You must attach supporting documents to show that your institution is capable of complying with the HEAL Statute, regulations, and policy

EMAIL ADDRESS _ TELEPHONE NO. ( )_ _

FAX NO. ( )_ _

• Claims Questions:

CONTACT NAME:_ _ ADDRESS:

^{directives. In addition to other information you may wish to submit, you} _

must submit the following:

• If the applicant is a commercial institution, a copy of the latest Annual Report;

• If the applicant is a lender for other Federal/State programs, a copy of your latest Call Report showing the loan activities (delinquency/default rates, etc.);

• If the applicant is a State Agency, a copy of your latest State Agency

EMAIL ADDRESS _ TELEPHONE NO. ( )_ _

FAX NO. ( )_ _

• Entity serving as your Loan Servicer:

CONTACT NAME:_ _

COMPANY NAME:_ _ ADDRESS:

reports submitted to the Department of Education showing loan ^_

activities (delinquency/default rates, etc.).

CONTACT INFORMATION

In the next column please provide the requested information of the officials who will serve as the points of contact to receive the following. (You must report any directory changes occurring during the application period to the HEAL Program.)

CODE NUMBER

EMAIL ADDRESS _ TELEPHONE NO. ( )_ _

FAX NO. ( )_ _

• Customer Service Contact Number( )_ _

HEAL-504

DEPARTMENT OF EDUCATION FEDERAL STUDENT AID APPLICATION FOR CONTRACT OF FEDERAL LOAN INSURANCE (Authority: 42 U.S.C. 292-292o)

OMB EXP.

NO. 1845-0128 DATE XXXXXXX

DATE

OF

APPLICATION

PLEASE FORWARD ONE EXECUTED APPLICATION AND REQUIRED ATTACHMENTS TO: DEPARTMENT OF EDUCATION Health Education Assistance Loan (HEAL) Program 830 First Street NE Room 44B4 Washington, DC 20202-5454

We hereby apply for a contract under the provisions of Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 292-292o) and the Consolidated Appropriations Act, 2014 and the regulations of the Secretary issued there under. We submit this application for the period to and the attached information, incorporated in and made a part hereof (see instructions).

1a. NAME (Exact corporate title) AND ADDRESS (Street, City, State and Zip Code)

1 b. CODE NUMBER CODE NUMBER

2. TYPE OF INSTITUTION (Check applicable box) NATIONAL BANK STATE BANK (Member FDIC) STATE BANK (Nonmember FDIC) FEDERAL SAVINGS AND LOAN

STATE SAVINGS AND LOAN FEDERAL CREDIT UNION STATE CREDIT UNION MUTUAL SAVINGS BANK

INSURANCE COMPANY PENSION FUND SCHOOL LENDER OTHER (Specify)

ITEMS 3 and 4 TO BE COMPLETED BY ALL APPLICANTS EXCEPT FOR ACADEMIC INSTITUTIONS OR STATE LOAN AGENCIES.

3. DATE ORGANIZED

4. INCORPORATED UNDER LAWS OF

5. WE ARE SUBJECT TO (Check applicable box) FEDERAL SUPERVISION BY:

STATE SUPERVISION

OTHER

I agree to develop and follow written procedures for servicing and collection of HEAL loans. Although HEAL Policy 2004-1 no longer requires biennial audit be conducted as specified in Section 681.42(d), we strongly encourage you to conduct such an audit. I also agree to incorporate any of our servicing and collection procedures used for our other loans of comparable dollar value that are more stringent than those required by Sections 681.34 of the HEAL regulations. In addition, I certify that neither this institution, nor any of its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency Sub-awardees (e.g., other corporations, partnerships, or other legal entities) have also provided the same certification to this institution.

SIGNATURE OF OFFICER

TYPED NAME AND TITLE OF OFFICER

DATE

WARNING: Any persons who knowingly makes a false statement or misrepresentation in a HEAL transaction, bribes, or attempts to bribe a Federal official, fraudulently obtains a HEAL Loan or comments any other illegal action in connection with a HEAL loan is subject to a fine or imprisonment under Federal statute.

FOR GOVERNMENT USE ONLY

APPROVED DISAPPROVED

HEAL-504

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