1845_0065_TPD-PDM_Exp 20220930

POST-DISCHARGE MONITORING: TOTAL AND
PERMANENT DISABILITY

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
TPD-PDM
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: DISCHARGE RECIPIENT INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
City

State

Zip Code

Telephone - Primary
Telephone - Alternate
Email
SECTION 2: DOCUMENTATION OF EARNED INCOME
Carefully read the entire form. Type or print in dark ink. Sign and date the form in Section 3. Include your name and Social
Security Number on any documentation that you submit with this form. Submit this form to the address in Section 6.
We will reinstate your obligation to repay a discharged loan or complete a discharged TEACH Grant service obligation if (1)
you receive annual earnings from employment above the poverty guideline for a family size of two for any of the three years
after the date we granted your discharge or (2) you do not respond to our request to complete and submit this form.
The poverty guidelines are issued annually by the U.S. Department of Health and Human Services, and are available at:
aspe.hhs.gov/poverty. For 2019, the poverty guidelines for a family size of two are:
Family Size 48 States & DC
2
$16,910

Alaska
$21,130

Hawaii
$19,460

Did you have income earned from employment between

If you do not live in one of the 50 states or DC, we
will use the poverty guideline for the 48 states.
and

?

Yes - You must provide documentation of all income you receive from employment or self-employment. See below.
No - By signing this form, you are certifying that you had no earned income from employment during the period
identified above. Continue to Section 3.
Acceptable Documentation of Earned Income (copies of original documentation are acceptable)
• You must provide one piece of documentation for each source of income from employment. Examples include a
federal or state income tax return, a W-2, a federal income tax return transcript, a Social Security Administration
earnings statement, a state or local agency earnings statement, or a pay stub from any employment.
• Unless the frequency is clearly indicated on the documentation that you provide, write on your documentation how
often you receive the income, for example, “twice per month” or “every other week”.
• If you are submitting documentation of income that you receive on a calendar-year basis, but a portion of the income
in the documentation is outside of the period for which you are providing documentation, write on your
documentation the amount of the income that you received during the period identified above.
• If no documentation of your earned income is available, submit a signed statement explaining the amount and
source of your earned income.
Do not provide documentation of unearned income, such as income from interest or dividends. Do not report
untaxed income, such as Supplemental Security Income, child support, or federal or state public assistance.
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Recipient Name

Recipient SSN

SECTION 3: RECIPIENT'S UNDERSTANDINGS AND CERTIFICATION
I understand that I may be required to repay my discharged loans and/or complete my discharged TEACH Grant service
obligation if, during the three-year post-discharge monitoring period, which begins on the date that I receive a discharge:
1. I receive annual earnings from employment that exceed the poverty guideline amount for a family of two in my state,
regardless of my actual family size;
2. I receive a new loan under the Direct Loan Program or a new TEACH Grant;
3. I receive a disbursement of a Direct Loan or TEACH Grant that was initially disbursed prior to my discharge date and I fail
to ensure that the disbursement is returned to the loan holder or (for a TEACH Grant) to the U.S. Department of
Education within 120 days of the disbursement date; or
4. The Social Security Administration determines that I am no longer disabled or changes my continuing disability review
period to a period that is shorter than 5-7 years or more, after I had been previously determined to be disabled by the
Social Security Administration and was receiving SSDI or SSI benefits with a continuing disability review period of 5-7
years or more.
I certify that all of the information I have provided on this form and in any accompanying documentation is true, complete,
and correct to the best of my knowledge and belief.
Representative Name (if applicable)
Date
Recipient's or Representative's Signature
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.
SECTION 4: DEFINITIONS
A discharge due to a total and permanent disability
cancels your obligation (and, if applicable, an endorser's
obligation) to repay the remaining balance on your
discharged loans or to satisfy your discharged TEACH Grant
service obligation.

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.
A representative is a member of your family, your
attorney,
a law firm or legal aid society, or another
The post-discharge monitoring period begins on the
individual
or organization authorized to act on your
date the U.S. Department of Education grants a discharge of
your loan or TEACH Grant service obligation and lasts for three behalf in connection with your total and permanent
years. If you fail to meet certain conditions at any time during disability discharge application.
or at the end of the post-discharge monitoring period, the U.S.
Department of Education will reinstate your obligation to
repay your loan or complete your TEACH Grant service
obligation. See Section 5 for more information.
The William D. Ford Federal Direct Loan (Direct Loan)
Program includes Direct Subsidized Loans, Direct
Unsubsidized Loans, Direct PLUS Loans, and Direct
Consolidation Loans.

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SECTION 5: IMPORTANT INFORMATION ABOUT THE POST-DISCHARGE MONITORING PERIOD
Post-discharge monitoring period
Reinstatement of obligation to repay a loan or complete a
TEACH Grant service obligation
If you were granted a discharge, we will monitor your
If you do not meet the requirements outlined above at any
status during the 3-year post-discharge monitoring period
time during or at the end of the post-discharge monitoring
that begins on the date the discharge is granted. We will
period, we will reinstate your obligation to repay your loans
reinstate your obligation to repay your loan(s) and/or to
and/or to complete your TEACH Grant service.
complete your TEACH Grant service if, at any time during the
If your loan is reinstated, you will be responsible for
post-discharge monitoring period, you:
repaying your loans to us in accordance with the terms of
• Receive annual earnings from employment that
your promissory note(s). Your loans will be returned to the
exceed the poverty guideline amount for a family of
status that would have existed if we had not received your
two in your state, regardless of your actual family size;
total and permanent disability discharge application.
• Receive a new loan under the Direct Loan Program or
However, you will not be required to pay interest on your
a new TEACH Grant;
loans for the period from the date of the discharge until the
• Receive a disbursement of a Direct Loan or TEACH
date your repayment obligation was reinstated. We will be
Grant that was initially disbursed prior to your
your loan holder.
discharge date and fail to ensure that the
If your TEACH Grant service obligation is reinstated, you
disbursement is returned to the loan holder or (for a
will again be subject to the requirements of your TEACH Grant
TEACH Grant) to us within 120 days of the
Agreement to Serve. If you do not meet the terms of that
disbursement date; or
agreement and the TEACH Grant funds you received are
• If your discharge was based on Social Security
converted to a Direct Unsubsidized Loan, you must repay that
Administration (SSA) documentation, you receive a
loan in full, and interest will be charged from the date(s) that
notice from the SSA indicating that you are no longer the TEACH Grant funds were disbursed.
disabled or that your continuing disability review will
If your obligation to repay your loans or complete your
no longer be 5 to 7 years or more from the date of
TEACH Grant service obligation is reinstated, we will notify
your last SSA disability determination.
you of the reinstatement. This notification will include:
• The reason or reasons for the reinstatement;
During the 3-year post-discharge monitoring period, we
will monitor the National Student Loan Data System (NSLDS)
• For loans, an explanation that the first payment due
to determine whether you have received a new loan under
date on the loan following the reinstatement will be
the Direct Loan Program or a TEACH Grant, or whether you
no earlier than 60 days following the date of the
have failed to ensure that a loan or TEACH Grant
notification of reinstatement; and
disbursement was returned to the loan holder or (for a TEACH
• Information on how you may contact us if you have
Grant) to us within 120 days of the disbursement date.
questions about the reinstatement, or if you believe
During the 3-year post-discharge monitoring period, you
that your obligation to repay a loan or complete
(or your representative) must:
TEACH Grant service was reinstated based on
incorrect information.
• Promptly notify us if your annual earnings from
employment exceed the poverty guideline amount
for a family of two in your state, regardless of your
actual family size;
• Promptly notify us of any changes in your address or
telephone number;
• Provide us with documentation of your annual
earnings from employment, on a form that we will
provide; and
• If your discharge was based on SSA documentation,
promptly notify us if the SSA determines that you are
no longer disabled or changes your continuing
disability review period to a period that is shorter than
5 to 7 years.

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SECTION 6: WHERE TO SEND THE COMPLETED FORM
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 711, then phone no.)
Fax: 303-696-5250
Email: [email protected]
Website: www.disabilitydischarge.com

SECTION 7: 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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