Direct Loan, FFEL, Perkins, and TEACH Grant Total and Permanent Disability Discharge Application and Related Forms

DISCHARGE APPLICATION: TOTAL AND PERMANENT
DISABILITY
TPD-APP

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan)
Program / TEACH Grant Program

This is an application for a total and permanent disability
(TPD) discharge of your Direct Loan, FFEL, and/or Perkins
Loan program loan(s), and/or your Teacher Education
Assistance for College and Higher Education (TEACH) Grant
Program service obligation.
Throughout this application, the words “we,” “us,” and
“our” refer to the U.S. Department of Education.
Make sure that all requested information is included.
Incomplete information may cause your application to be
delayed or rejected. To qualify for this discharge, you must
submit documentation from one of the following sources:

Your discharged loans or TEACH Grant service obligation
may be reinstated if you do not meet certain requirements,
as explained in Section 6 of this form.
Physician Certification
You may qualify for discharge by having a physician
complete Section 4 of this application. The physician must
certify that you are unable to engage in any substantial
gainful activity (see definition in Section 5) by reason of a
medically determinable physical or mental impairment that:
1. Can be expected to result in death;
2. Has lasted for a continuous period of at least 60
months; or
3. Can be expected to last for a continuous period of at
least 60 months.

1. The U.S. Department of Veterans Affairs (VA) OR
2. The Social Security Administration (SSA) OR
3. A physician's certification in Section 4 of this form
Except for VA or SSA determinations described below, a
disability determination by another federal or state agency
does not qualify you for this discharge.
U.S. Department of Veterans Affairs Documentation
If you are a veteran who has been determined by the VA
to be unemployable due to a service-connected disability,
you may qualify for discharge by providing documentation
from the VA showing that you have received one of the
following two types of VA disability determinations:
1. A determination that you have a service-connected
disability (or disabilities) that is 100% disabling.
2. A determination that you are totally disabled based
on an individual unemployability rating.
You do not qualify for discharge based on a VA disability
determination if your disability is not service-connected.
Social Security Administration Documentation
If you are eligible for Social Security Disability Insurance
(SSDI) or Supplemental Security Income (SSI), you may
qualify for discharge by providing a copy of your notice of
award or Benefits Planning Query (BPQY) from the SSA. You
only qualify for a discharge based on this documentation if
it shows that your next scheduled disability review will be 5
to 7 years or more from the date of your last SSA disability
determination.
If you want to submit a BPQY but do not have one,
contact the SSA office that issued your award and request
form SSA-2459. You may also request a BPQY by calling
1-800-772-1213 or by visiting www.ssa.gov.

OMB No. 1845-0065
OMB Approved
Exp. Date 9/30/2022

If you are granted a discharge based on a physician's
certification, we will monitor your status during a 3-year
monitoring period. Your discharged loans or TEACH Grant
service obligation may be reinstated if you do not meet
certain requirements, as explained in Section 6 of this form.
Important Tax Information
Loan amounts discharged due to TPD are not considered
taxable income by the Internal Revenue Service (IRS) for
federal tax purposes. However, certain states may consider
the discharged amount to be income for state tax purposes.
Check with your state tax office or a tax professional before
filing your state tax return.
How to Designate Someone to Represent You
If you wish to designate someone to represent you in
matters related to your discharge request, you must
complete the Applicant Representative Designation: Total
and Permanent Disability form. You may obtain this form
from our TPD Discharge Servicer (see below for contact
information).
WHERE TO SEND YOUR COMPLETED APPLICATION AND
DOCUMENTATION
U.S. Department of Education - TPD Servicing
P.O. Box 87130
Lincoln, NE 68501-7130
Fax: 303-696-5250
IF YOU NEED HELP COMPLETING THE APPLICATION

If you are granted a discharge based on SSA
documentation, we will monitor your status during a 3-year
monitoring period.
Page 1 of 8

Phone: 1-888-303-7818 (TTY: dial 711, then phone no.)
Email: [email protected]
Website: www.disabilitydischarge.com

DISCHARGE APPLICATION: TOTAL AND PERMANENT
DISABILITY
TPD-APP

OMB No. 1845-0065
OMB Approved
Exp. Date 9/30/2022

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan)
Program / TEACH Grant 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: APPLICANT INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Date of Birth
Name
Address
City

State

Zip Code

Telephone - Primary
Telephone - Alternate
Email
SECTION 2: TOTAL AND PERMANENT DISABILITY INFORMATION
Carefully read the entire application. Type or print in dark ink. Sign and date the application in Section 3.
2. Are you currently receiving SSDI or SSI benefits, and
does your most recent notice of award of Benefits
Planning Query (BPQY) from the SSA state that your
next scheduled disability review will be 5 to 7 years
or more from the date of your last SSA disability
determination?
Yes - Attach a copy of your most recent SSA notice of
award or BPQY and complete Section 3. You do not
need to have a physician complete Section 4.
No - Complete Section 3 and have a physician
complete and sign Section 4.
SECTION 3: APPLICANT'S REQUEST, AUTHORIZATION, UNDERSTANDINGS, AND CERTIFICATIONS
I request that the U.S. Department of Education discharge my Direct Loan, FFEL, and/or Perkins Loan program loan(s), and/or
my TEACH Grant service obligation.
I authorize any physician, hospital, or other institution having records about the disability that is the basis for my request for
a discharge to make information from those records available to the U.S. Department of Education.
I understand that:
1. If I am applying for a discharge based on a physician's certification in Section 4, I must submit this application to the
U.S. Department of Education within 90 days of the date of my physician's signature in Section 4.
2. If I am a veteran who answered No to Item 1 in Section 2, and I obtained a certification from a physician in Section 4,
that certification is only for purposes of determining my eligibility for a discharge of my loan(s) or TEACH Grant service
obligation, and is not for purposes of determining my eligibility for, or the extent of my eligibility for, VA benefits.
I certify that: (1) I have a total and permanent disability, as defined in Section 5; and (2) I have read and understand the
information in Sections 6 and 7.
1. Are you a veteran who has received a determination
from the U.S. Department of Veterans Affairs (VA) that
you are unemployable due to a service-connected
disability?
Yes - Attach documentation of the VA determination
and complete Section 3. You do not need to have a
physician complete Section 4.
No - Continue to Item 2.

Representative Name (if applicable)
Applicant's or Representative's Signature
Date
NOTE: You may designate someone to represent you in matters related to your application. If you wish to designate a
representative, you must complete the Applicant Representative Designation: Total and Permanent Disability form.
Page 2 of 8

Applicant Name

Applicant SSN

SECTION 4: PHYSICIAN'S CERTIFICATION
Print legibly and initial any changes. Return the form to the
applicant or representative.
Applicant Identification
1. Provide the below information regarding the individual for
whom you are completing this Section:
Name

6. Describe the severity of the applicant's impairment,
including, if applicable, the phase of the impairment:

Date of Birth
Medically Determinable Physical or Mental Impairment
2. Does the applicant have a medically determinable physical or
mental impairment that prevents the applicant from
engaging in any substantial gainful activity?
Substantial gainful activity means a level of work
performed for pay or profit that involves doing significant
physical or mental activities or a combination of both. If the
applicant is able to engage in any substantial gainful activity
in any field of work, you must answer "No".
Yes - Continue to Item 3.
No - Do not complete this application.

Limitations
Explain how the condition prevents the applicant from
engaging in any substantial gainful activity in any field of work.
Attach additional pages if needed. Enter "N/A" if not applicable.
You may include additional information you believe is helpful in
understanding the applicant's condition, such as medications or
procedures used to treat the condition.
7. Limitations on sitting, standing, walking, or lifting:

8. Limitations on activities of daily living:

Severity/Duration of Physical or Mental Impairment
3. Is the applicant's impairment expected to result in death?
Yes - Skip to Item 5.

9. Residual functionality:

No - Continue to Item 4.
4. Has the applicant's impairment lasted or is it expected to last
for a continuous period of at least 60 months?
Yes - Continue to Item 5.
No - Do not complete this application.

10. Social/behavioral limitations (if any):

Disabling Condition
Do not use insurance codes or abbreviations.
11. Global Assessment Function Score (for psychiatric conditions):

5. Provide your diagnosis of the applicant's impairment:

Physician's Certification
I certify that, in my best professional judgment, the applicant identified in Item 1 has a medically determinable physical or mental
impairment consistent with my responses in Items 2 through 10.
I understand that an applicant who is currently able to engage in any substantial gainful activity in any field of work does not have a total
and permanent disability as defined on this form.
I am a doctor of:

medicine

osteopathy/osteopathic medicine

State Where Legally Authorized to Practice*

Professional License Number (subject to verification; stamp is acceptable)

*If you are licensed to practice in American Samoa, Puerto Rico, the U.S. Virgin Islands, the Northern Mariana Islands, the Marshall Islands,
Micronesia, or Palau, attach a copy of your professional license that clearly shows the expiration date.

Physician's Signature (a stamp is not acceptable)

Date (mm-dd-yyyy)
Email

Address (a stamp is acceptable)

Page 3 of 8

Physician Name (First, Middle, Last)
Telephone
Fax

SECTION 5: DEFINITIONS
If you have a total and permanent disability, this means
that: (1) you are unable to engage in any substantial gainful
activity by reason of a medically determinable physical or
mental impairment that can be expected to result in death, or
that has lasted for a continuous period of not less than 60
months, or that can be expected to last for a continuous
period of not less than 60 months; OR (2) you are a veteran
who has been determined by the VA to be unemployable due
to a service-connected disability. Except for certain individuals
who have received SSA notices of award for SSDI or SSI
benefits, or for certain veterans, a disability determination by
another federal or state agency does not establish your
eligibility for a discharge of your loan(s) and/or TEACH Grant
service obligation due to a total and permanent disability.
Substantial gainful activity means a level of work
performed for pay or profit that involves doing significant
physical or mental activities, or a combination of both.
A discharge of a loan due to a total and permanent
disability cancels your obligation (and, if applicable, an
endorser's obligation) to repay the remaining balance on your
Direct Loan, FFEL, and/or Perkins Loan program loans. A
discharge of a TEACH Grant service obligation cancels your
obligation to complete the teaching service that you agreed
to perform as a condition for receiving a TEACH Grant.
The post-discharge monitoring period begins on the
date we grant a discharge of your loan(s) or TEACH Grant
service obligation and lasts for three years. If you fail to meet
certain conditions at any time during or at the end of the postdischarge monitoring period, we will reinstate your obligation
to repay your loan(s) or complete your TEACH Grant service.
See Section 6 for more information.
Note to Veterans: The post-discharge monitoring period
does not apply if you are a veteran who receives a discharge
based on a determination from the VA that you are
unemployable due to a service-connected disability.
The William D. Ford Federal Direct Loan (Direct Loan)
Program includes Federal Direct Stafford/Ford Loans (Direct
Subsidized Loans), Federal Direct Unsubsidized Stafford/Ford
Loans (Direct Unsubsidized Loans), Federal Direct PLUS Loans
(Direct PLUS Loans), and Federal Direct Consolidation Loans
(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 Federal Perkins Loan (Perkins Loan) Program
includes Federal Perkins Loans, National Direct Student
Loans (NDSL), and National Defense Student Loans (Defense
Loans).
The Teacher Education Assistance for College and
Higher Education (TEACH) Grant Program requires
individuals to complete a teaching service obligation as a
condition for receiving a TEACH Grant.
The holder of your FFEL Program loan(s) may be a
lender, a guaranty agency, or the U.S. Department of
Education. The holder of your Perkins Loan Program loan(s)
may be a school you attended or the U.S. Department of
Education. The holder of your Direct Loan Program loan(s)
and/or your TEACH Grant Agreement to Serve (if you
received a TEACH Grant) is the U.S. Department of
Education. Your loan holder may use a servicer to handle
billing and other matters related to your loan. The term
“holder” as used on this application means either your loan
holder or, if applicable, your loan servicer.
The term “state” for purposes of the physician's
certification in Section 4 (the physician must be licensed to
practice in a state) includes the 50 United States, the District
of Columbia, American Samoa, the Commonwealth of
Puerto Rico, Guam, the U.S. Virgin Islands, the
Commonwealth of the Northern Mariana Islands, the
Republic of the Marshall Islands, the Federated States of
Micronesia, and the Republic of Palau.
A representative is a member of your family, your
attorney, a law firm or legal aid society, or another
individual or organization authorized to act on your behalf
in connection with your total and permanent disability
discharge application.

SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE
Applying for discharge (all applicants):
Submission of discharge application. After you submit
your completed application and documentation to us, we will
send you a notice that will:
• Acknowledge receipt of your application;
• Explain the process for our review of your application;
and
• Inform you that you are not required to make any
payments on your loans while we review your
application for discharge.

Consequences of failure to submit an application. If
you do not submit an application to us within 120 days of
notifying us that you intend to submit an application,
collection activity will resume on your loans, and your loan
holder may capitalize any unpaid interest. This means that
the unpaid interest will be added to the principal balance of
your loans, and interest will then be charged on the
increased loan principal amount. However, if you have a
FFEL Program loan and the loan holder is a guaranty
agency, or if you have a Federal Perkins Loan, unpaid
interest will not be capitalized.

Page 4 of 8

SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (CTD.)
Discharge process for veterans who have been determined
by the VA to be unemployable due to a service-connected
disability:
Our review of your discharge application. We will
review the documentation from the VA to determine if you
are totally and permanently disabled as described in item (2)
of the definition of “total and permanent disability” in
Section 5 of this application.
Determination of eligibility or ineligibility for
discharge. If we determine that you are totally and
permanently disabled, you will be notified that your loans
and/or TEACH Grant service obligation has been discharged.
The discharge will be reported to nationwide consumer
reporting agencies, and any loan payments received on your
loan on or after the effective date of the determination by
the VA that you are unemployable due to a serviceconnected disability will be refunded to the person who
made the payments.
If we determine that you are not totally and
permanently disabled, you will be notified of that
determination. The notification will include:
• The reason or reasons for the denial of your discharge
application;
• An explanation that your loans are due and payable
to the loan holder under the terms of the promissory
note that you signed and that your loans will return
to the status they were in at the time you applied for
a total and permanent disability discharge;
• An explanation that your loan holder will notify you
of the date you must resume making payments on
your loans; and
• An explanation that if you applied for a discharge of a
TEACH Grant service obligation, you must comply
with all terms and conditions of your TEACH Grant
Agreement to Serve.
The notification will also explain your ability to request
reconsideration of this determination or to submit a new
discharge application:
• You may request that we re-evaluate your discharge
application by providing additional documentation
from the VA that supports your eligibility for
discharge. If you provide this documentation within
12 months of the date of our notification that you are
ineligible for discharge, you do not have to submit a
new application. After 12 months, a new application
is required.
• If the documentation from the VA does not indicate
that you are unemployable due to a serviceconnected disability, you may reapply for discharge
under the “Discharge Process For All Other
Applicants”. You must submit a new application with
the required documentation from the SSA or a
physician's certification in Section 4.

Discharge process for all other applicants:
Our review of your discharge application. If you
submit a discharge application supported by an award of
benefits notice from the SSA or an SSA Benefits Planning
Query (BPQY), we will review that documentation to
determine if it meets the requirements described in Section
2, Item 2 of this form.
If you submit a discharge application supported by a
physician's certification in Section 4 of this application, we
will review the physician's certification and any
accompanying documentation to determine if you are
totally and permanently disabled as described in item (1) of
the definition of “total and permanent disability” in Section 5
of this application. We may also contact your physician for
additional information, or may arrange for an additional
review of your condition by an independent physician at our
expense. Based on the results of this review, we will
determine your eligibility for discharge.
If we determine during our review of your application
that you received a Direct Loan or a TEACH Grant before the
date we received the SSA notice of award (or BPQY) or
before the date the physician certified your application in
Section 4, and a disbursement of that loan or grant is made
after that date, but before we have granted a discharge, we
will suspend processing of your discharge request until you
ensure that the full amount of the disbursement is returned
to the loan holder or (for a TEACH Grant) to us.
If you apply for a total and permanent disability
discharge and we determine as part of our review that a new
Direct Loan or a new TEACH Grant was made to you on or
after the date we received the SSA notice of award (or BPQY)
or the date the physician certified your application in
Section 4, and before the date we grant a discharge, we will
deny your discharge request. Collection will resume on your
loans and you will again be responsible for complying with
the terms and conditions of your TEACH Grant Agreement to
Serve.
Determination of eligibility or ineligibility for
discharge. If we determine that you are totally and
permanently disabled, we will notify you that a discharge
has been approved, and that you will be subject to a postdischarge monitoring period for three years beginning on
the discharge date. The notification of discharge will explain
the terms and conditions under which we will reinstate your
obligation to repay your loan or to complete your TEACH
service. The discharge will be reported to nationwide
consumer reporting agencies, and any loan payments that
were received after the date we received the SSA notice of
award (or BPQY) or after the date the physician certified your
discharge application will be returned to the person who
made the payments.

Page 5 of 8

SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (CTD.)
Post-discharge monitoring period. If you are granted a
discharge, we will monitor your status during the 3-year
post-discharge monitoring period that begins on the date
the discharge is granted.

Discharge process for all other applicants (continued):
Determination of eligibility or ineligibility for
discharge (continued).
If we determine that you are not totally and
permanently disabled, you will be notified of that
determination. The notification will include:
• The reason or reasons for the denial of your discharge
application;

We will reinstate the requirement for you to repay your
loans and/or complete your TEACH Grant service if, at any
time during or at the end of the post-discharge monitoring
period, you:
• Receive annual earnings from employment that
exceed the poverty guideline amount (see Note
below) for a family of two in your state, regardless of
your actual family size;

• An explanation that your loans are due and payable
to the loan holder under the terms of the promissory
note that you signed and that your loans will return
to the status that would have existed if your total and
permanent disability discharge application had not
been received;

• Receive a new loan under the Direct Loan Program or
a new TEACH Grant;
• Receive a disbursement of a Direct Loan Program
loan or a TEACH Grant that was initially disbursed
prior to your discharge date and you fail to ensure
that the disbursement is returned to the loan holder
or (for a TEACH Grant) to us within 120 days of the
disbursement date; or

• An explanation that your loan holder will notify you
of the date you must resume making payments on
your loans;
• An explanation that if you applied for a discharge of a
TEACH Grant service obligation, you must comply
with all terms and conditions of your TEACH Grant
Agreement to Serve;
• An explanation that you are not required to submit a
new total and permanent disability discharge
application if, within 12 months of the date of our
notification to you that you are ineligible for
discharge, you provide additional information
regarding your disabling condition that supports
your eligibility for discharge, and you request that we
re-evaluate your discharge application; and
• An explanation that if you do not request reevaluation of your prior discharge application within
12 months of the date of our notification of
ineligibility for discharge, and you still wish to have
us re-evaluate your eligibility for a total and
permanent disability discharge, you must submit a
new total and permanent disability discharge
application to us.

• Receive a notice from the SSA indicating that you are
no longer disabled or that your continuing disability
review will no longer be the 5- to 7-year period
indicated in the SSA notice of award or BPQY.
During the 3-year post-discharge monitoring period, you
(or your representative) must:
• Promptly notify us of any changes in your address or
telephone number;
• Promptly notify us if your annual earnings from
employment exceed the poverty guideline amount
for a family of two in your state (see Note below),
regardless of your actual family size;
• Upon request, provide us with documentation of
your annual earnings from employment, on a form
that we will provide; and
• Promptly notify us if you receive a notice from the
SSA indicating that you are no longer disabled or that
your continuing disability review will no longer be
the 5- to 7-year period indicated in the SSA notice of
award or BPQY (after you had been previously
determined to be disabled by the SSA, were receiving
SSDI or SSI benefits, and had a continuing disability
review period of 5 to 7 years or more from the date of
your last SSA disability determination).

• If you request a re-evaluation of your total and
permanent disability discharge application or submit
a new total and permanent disability discharge
application, as described above, your request must
include new information regarding your disabling
condition that was not provided to us in connection
with your prior application for discharge.

Note: The poverty guideline amounts are updated
annually and may be obtained at http://aspe.hhs.gov/
poverty. We will notify you of the current poverty guideline
amounts during each year of the post-discharge monitoring
period.
Page 6 of 8

SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (CTD.)
Discharge process for all other applicants (continued):
Reinstatement of obligation to repay discharged
loans or complete discharged TEACH Grant service
obligation. If you do not meet the requirements described
above at any time during or at the end of the post-discharge
monitoring period, we will reinstate your obligation to repay
your loans and/or to complete your TEACH Grant service. If
your loans are reinstated, you will be responsible for
repaying your loans to us in accordance with the terms of
your promissory note(s). Your loans will be returned to the
status that would have existed if we had not received your
total and permanent disability discharge application.
However, you will not be required to pay interest on your
loans for the period from the date of the discharge until the
date your repayment obligation was reinstated. We will be
your loan holder. If your TEACH Grant service obligation is
reinstated, you will again be subject to the requirements of
your TEACH Grant Agreement to Serve. If you do not meet
the terms of that agreement and the TEACH Grant funds you
received are converted to a Direct Unsubsidized Loan, you
must repay that loan in full, and interest will be charged
from the date(s) that the TEACH Grant funds were disbursed.

If your obligation to repay your loans or to complete your
TEACH Grant service is reinstated, we will notify you of the
reinstatement. This notification will include:
• The reason or reasons for the reinstatement;
• For loans, an explanation that the first payment due
date on the loan following the reinstatement will be
no earlier than 60 days following the date of the
notification of reinstatement; and
• Information on how you may contact us if you have
questions about the reinstatement, or if you believe
that your obligation to repay a loan or complete
TEACH Grant service was reinstated based on
incorrect information.

SECTION 7: ELIGIBILITY REQUIREMENTS TO RECEIVE FUTURE LOANS OR TEACH GRANTS
For veterans who receive a total and permanent disability
discharge based on a determination by the VA that they
are unemployable due to a service-connected disability:
If you are a veteran who is granted a discharge based on a
determination that you are totally and permanently disabled
as described in item (2) of the definition of “total and
permanent disability” in Section 5 of this application, you are
not eligible to receive future loans under the Direct Loan
Program or future TEACH Grants, unless:

For all other individuals who receive a total and
permanent disability discharge:
If you are granted a discharge based on a determination
that you are totally and permanently disabled in accordance
with item (1) of the definition of “total and permanent
disability” in Section 5 of this application, you are not
eligible to receive future loans under the Direct Loan
Program or future TEACH Grants, unless:

• You obtain a certification from a physician that you
are able to engage in substantial gainful activity; and
• You sign a statement acknowledging that the new
loan or TEACH Grant service obligation cannot be
discharged in the future on the basis of any injury or
illness present at the time the new loan or TEACH
Grant is made, unless your condition substantially
deteriorates so that you are again totally and
permanently disabled.

Page 7 of 8

• You obtain a certification from a physician that you
are able to engage in substantial gainful activity;
• You sign a statement acknowledging that the new
loan or TEACH Grant service obligation cannot be
discharged in the future on the basis of any injury or
illness present at the time the new loan or TEACH
Grant is made, unless your condition substantially
deteriorates so that you are again totally and
permanently disabled; and
• If you request a Direct Loan Program loan or a new
TEACH Grant within three years of the date that a
previous loan or TEACH Grant was discharged, you
resume payment on the previously discharged loan
or acknowledge that you are once again subject to
the terms of the TEACH Grant Agreement to Serve
before receiving the new loan.

SECTION 8: WHERE TO SEND THE COMPLETED DISCHARGE APPLICATION
Return the completed form and any documentation to:

If you need help completing this form, contact us:

U.S. Department of Education - TPD Servicing
P.O. Box 87130
Lincoln, NE 68501-7130
Fax to: 303-696-5250
Email to: [email protected]

Phone: 1-888-303-7818 (TTY: dial 771, then phone no.)
Email: [email protected]
Website: www.disabilitydischarge.com

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., §461, or
§420L of the Higher Education Act of 1965, as amended (20
U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa
et seq., or 20 U.S.C. 1070g 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 Direct
Loan,FFEL, Perkins Loan, or TEACH Grant 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, Federal Perkins
Loan or TEACH Grant 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 such
collection displays a valid OMB control number. The valid
OMB control number for this information collection is
1845-0065. 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
collection of information. The obligation to respond to this
collection is required to obtain a benefit in accordance with
34 CFR 674.61(b) or (c), 34 CFR 682.402(c)(2) or (c)(9), 34 CFR
685.213(b) or (c), and 34 CFR 686.42(b). If you have
comments or concerns regarding the status of your
individual submission of this form, please contact the U.S.
Department of Education directly (see Section 6).

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