heald-attestation-form Edits from 30D comments CLEAN

FORM Under Review OMB NO: 1845-0132 Exp. xx/xx/xxxx

UNITED STATES DEPARTMENT OF EDUCATION

ATTESTATION FOR CERTAIN HEALD
COLLEGE BORROWERS
(APPLICATION FOR BORROWER DEFENSE TO REPAYMENT LOAN DISCHARGE)
The Department of Education has found that at various times between 2010 and 2014, Heald College published
misleading job placement rates for many of its programs of study. This form is designed to expedite the process of
obtaining loan forgiveness based on borrower defense to repayment for loans taken out by Heald College borrowers to
enroll in these programs. This form covers federal Direct Loans (including Parent PLUS loans issued to parents of Heald
borrowers) received on or after July 1, 2010. A list of covered programs and dates of enrollment is available at
StudentAid.gov/sites/default/files/heald-findings.pdf.
Please fill out this attestation ONLY IF your program and dates of enrollment are included on this list.
Heald College students and, if applicable, parents with Parent PLUS loans who did not attend programs where the
Department of Education found misleading job placement rates, or whose decision to enroll was not influenced by those
job placement rates, may still be eligible for loan forgiveness based on borrower defense to repayment. Additional
instructions to file a claim for loan forgiveness can be found at StudentAid.gov/borrower-defense.
Instructions: Please complete this form (students and, if applicable, parents with Parent PLUS loans). To sign the form,
insert a digital image of your signature in the appropriate fieldbelow or print a hard copy of the form and sign. Submit
your form and all supplementary documents referenced in question #4 via email to [email protected] or mail
to US Department of Education - Borrower Defense to Repayment, PO Box 1854, Monticello, KY 42633.

SECTION I: BORROWER INFORMATION
Date of Birth

Name (First, Middle, Last)
Phone Number

Email Address

Home Address

I,

Social Security Number

City

State

Zipcode

, attest to the following:

I am submitting this attestation and additional materials in support of my application for a borrower defense to repayment
discharge of my Direct Loans under 34 C.F.R. §§ 685.206(c), 685.206(d), 685.222(d).

SECTION II: PROGRAM INFORMATION
If you, or your child in the case of Parent PLUS loans, enrolled in more than one covered Heald program, you will need to
complete the following for each covered program you, or your child, attended. For example, if you, or your child, were a
criminal justice student in 2011 and returned in 2012 for an accounting program, you should complete the first Campus
Program section based on your, or your child’s, enrollment in criminal justice and the second Campus Program section
based on your, or your child’s, enrollment in accounting.
If you, or your child in the case of Parent PLUS loans, have more than one program, click the Add Campus Program button
that appears at the bottom of the Campus Program section.
Note: This form applies to students and, if applicable, parents with Parent PLUS loans who enrolled in a program
after misleading placement rates were published for the program. A list of covered programs and dates of
enrollment is available at StudentAid.gov/sites/default/files/heald-findings.pdf. The earliest enrollment date covered
is July 1, 2010.

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EF

CAMPUS PROGRAM
Campus
Enrollment Start Date (mm/dd/yyyy)

Enrollment End Date (mm/dd/yyyy)

Program Name

Credential

1. Prior to my, or my child’s, enrollment in this Heald College program, I received information about job placement
rates related to my program of study through one or more of the following ways (check each that applies).
Brochures advertising Heald College's academic programs or other printed materials, including those provided
by Heald College representatives or recruiters;
Emails, online materials, or online disclosures from or by Heald College.
2. I believed that the job placement rates related to my, or my child’s, program of study indicated the level of quality a
Heald education offered to students. I, or my child, chose to enroll at Heald based, in substantial part, on the
information I, or my child, received about job placement rates related to my, or my child’s, program of study and the
quality of education I, or my child, believed those placement rates represented.
3. I applied for and received a federal Direct Loan to cover the cost of attendance of the Heald program in which
I, or my child, enrolled.
4. As an attachment to this attestation, I have included documents with additional information to confirm that I, or my
child, was enrolled in the program of study at Heald College that I identified above, and was enrolled for the dates
I provided above. Suggested documents include transcripts and registration documents indicating your, or your
child’s, specific program of study at Heald College and dates of enrollment. The documents I have attached are:

Select Add Another Date Range if you had multiple periods of enrollment in a program, that is, if you, or your child,
enrolled in a program but subsequently discontinued enrollment, and then reenrolled in the same program at a later date,
please provide all start and end dates applicable to this program. (This allows for multiple periods of enrollment. Select
Remove Another Date Range to remove any enrollment dates added in error.)
Add Another Date Range

Remove Another Date Range

Add New Campus Program:

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Add
Program

Remove Campus Program:

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Remove
Program

SECTION III: OTHER INFORMATION
Please provide or attach any other information about your experience at Heald College that you believe is relevant:
(2,000 characters max)

SECTION IV: DIRECT LOAN FORBEARANCE
By completing this form, you are eligible to have all of your federal loans placed into forbearance and for collections on
any federal loans in default to stop while your claim is reviewed by the Department of Education. Please read the
following information carefully before making your selection below.
During any period that your loans are in forbearance, you do not have to make payments on those loans, and the loans
will not go into default. If your loans are already in default, collections will stop. This will continue until the loan discharge
review process is completed. Your servicer will notify you when your loan has been placed into forbearance or stopped
collections. Until you receive that notice, you should continue to make payments.
The forbearance or stopped collections will affect all of a borrower's federal loans, including loans that are not eligible for
discharge through this form, such as Federal Family Education Loans (FFEL), loans taken out to attend a Heald College
program not on the enclosed list of covered programs, or loans taken out to attend another institution.
Note that interest will continue to accrue on all of these federal loans, including subsidized loans, during the
forbearance or stopped collections period.
If you want the forbearance or stopped collections to apply only to those loans that may be eligible for a discharge using
this form, you must notify your loan servicer. At any time during the forbearance or stopped collections period, you may
voluntarily make payments on your loans, including payments for accrued interest, or end the forbearance or stopped
collections by contacting your servicer.
If your claim made using this form is successful, your federal Direct Loans borrowed to attend a covered Heald College
program will be discharged. Also at that time, the forbearance or stopped collections period for your other federal loans
will end. You will be responsible for repaying these other remaining loans, including interest that accrued during the
forbearance or stopped collections period, under the terms of your promissory note.
If your claim is denied, you will not receive a discharge of any of your loans and the forbearance or stopped collections
period will end for all of your loans. You will be responsible for repaying these loans, including interest that accrued
during the forbearance or stopped collections period, under the terms of your promissory note.
Yes, I want my federal loans to be placed in forbearance and for collections to stop on any loans in default while my
loan discharge claim is reviewed.
No, I do not want my federal loans to be placed in forbearance and for collections to stop on any loans in default
while my loan discharge claim is reviewed.
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SECTION V: CERTIFICATION
By signing this attestation, I certify that:
I agree to provide, upon request, testimony, a sworn statement, or other documentation reasonably available to me that
demonstrates to the satisfaction of the Department of Education or its designee that I meet the qualifications for borrower
defense to repayment loan discharge.
All of the information I provided is true and complete to the best of my knowledge and I agree, if asked, to provide
information reasonably available to me to the Department of Education that will verify the accuracy of my completed
attestation.
I understand that the Department of Education has the authority to verify information reported on this application with
other federal or state agencies or other entities. I authorize the Department of Education, along with its agents and
contractors, to contact me regarding this request at the phone number above using automated dialing equipment or
artificial or prerecorded voice or text messages.
I understand that if I purposely provided false or misleading information on this application, I may be subject to the
penalties specified in 18 U.S. Code § 1001.
Signature

Date

PRIVACY ACT STATEMENT
Information required by subsection (e)(3) of the Privacy Act of 1974, as amended (Privacy Act) (5 U.S.C. 552a(e)
(3))requires the following notice be provided to you:
The authorities for collecting the requested information from and about you are Section 455(h) of the Higher Education
Act of 1965, as amended (HEA) (20 U.S.C. 1087e(h)) and 34 C.F.R. § 685.206(c) and the authorities for collecting and
using your Social Security Number (SSN) are the same but also include 31 U.S.C. 7701(b). The primary purpose of the
information collected is for the use and administration of the U.S. Department of Education's office of Federal Student
Aid (ED/we) for borrower defense to loan repayment program. The information you provide ED on this form and your
SSN are voluntary, but you may need to provide the requested information on this form, including your SSN and/or a
Federal Student Aid ID (FSA ID) that provides ED your verified SSN and other individual information pertaining to a
student's or parent's Student Financial Assistance Programs account(s), for ED to process or complete our review of
your borrower defense to loan repayment application. You may submit a form without your SSN or an FSA ID by filling
out a form and sending it to ED via email or physical mail because disclosure of the information requested on this form is
voluntary. However, without providing all the requested information on this form, ED may not be able to conduct a full
investigation and complete the review of your application.
We use the information that you provided on this form including your name, SSN, date of birth, address, email address,
telephone number(s), and / or an FSA ID, to receive, review, evaluate, and process requests for relief under the borrower
defense to loan repayment regulations, to render decisions on the merits of such requests for relief, and, where requests
for borrower defense to loan repayment are successful, to determine the relief that is appropriate to borrowers under the
circumstances as well as to initiate appropriate proceedings to require schools whose acts or omissions resulted in the
successful defenses against repayment to pay ED the amounts of the loans that apply to the defenses. Without your
consent, ED may disclose the information that you provided and as otherwise allowed by the Privacy Act, pursuant to the
routine uses identified in the system of records notice (SORN) entitled “Customer Engagement Management System
(CEMS)” (18-11-11) and published in the Federal Register as 83 FR 27587-27591 (June 13, 2018). These routine uses
include, but are not limited to, a routine use that permits ED to disclose your information to foreign agencies, Federal
agencies, State agencies, Tribal, or local agencies, accreditors, schools, lenders, guaranty agencies, servicers, and
private collection agencies when further information is relevant to ED's resolution of your complaint, request, or other
inquiry, tracking your application or your inquiry, and, where a request for borrower defense to loan repayment is
successful, to determine the relief that is appropriate under the circumstances as well as to initiate the appropriate
proceeding to require the school whose acts or omissions resulted in the successful defense against loan repayment to
pay ED the amount of the loan that apply to the defenses. We may use your information for reporting, analyzing the data
to make recommendations in student financial assistance programs, and assisting in the informal resolution of disputes.
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Disclosure of relevant information also may be made to the responsible foreign, Federal, State, Tribal or local agencies
charged with investigating or prosecuting a violation or potential violation of law in the event that information indicates,
either on its face or in connection with other information, a violation or potential violation of any applicable statute,
regulation, or order of a competent authority.
In the event of litigation or alternative dispute resolution (ADR) involving ED or that we have an interest in and if that a
party is either any component of ED, any ED employee in his or her official capacity, any ED employee in his or her
individual capacity where representation for the employee has been requested or has been agreed to by ED or the
Department of Justice (DOJ), or the United States where ED determines that the litigation is likely to affect ED or any of
its components, we may disclose your information to DOJ, a court, adjudicative body, a person or an entity designated
by ED or otherwise empowered to resolve or mediate disputes, or a counsel, party, representative, or witness if the
disclosure is relevant and necessary to the litigation or ADR. ED also may disclose your information to DOJ to the extent
necessary for obtaining DOJ's advice on any matter relevant to an audit, inspection, or other inquiry. We may send
information to members of Congress if you ask them to help you with federal student aid or Student Financial Assistance
Programs account(s) questions. Disclosures may be made to our contractors for the purpose of performing any
programmatic function that requires disclosure of records. As part of such a contract, we will require the contractor to
maintain safeguards to protect the security and confidentiality of the records that are disclosed to the contractor. If a
record is relevant and necessary to a borrower complaint regarding participants in any Federal Student Financial
Assistance Programs under title IV of the HEA, ED may disclose a record only during the course of processing,
reviewing, investigating, fact-finding, or adjudicating the complaint to: any party to the complaint; the party's counsel or
representative; a witness; or a designated fact-finder, mediator, or other person designated to resolve issues or decide
the matter. ED also may disclose records to the DOJ or Office of Management and Budget (OMB) if ED concludes that
disclosure is desirable or necessary in determining whether particular records are required to be disclosed under the
Freedom of Information Act (FOIA) or the Privacy Act. ED may disclose your information to appropriate agencies,
entities, and persons when ED suspects or has confirmed that there has been a breach of the system maintaining your
information; which poses a risk of harm to individuals, ED (including its information systems, programs, and operation),
the Federal agencies, or national security and the disclosure made to such agencies, entities, and persons is reasonably
necessary to assist ED's efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy
such harm. ED also may disclose your information to another Federal agency or Federal entity, when ED determines
that your information is reasonably necessary to assist the recipient agency or entity in responding to a suspected or
confirmed breach or preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity
(including its information systems, programs, and operations), the Federal agencies, or national security, resulting from a
suspected or confirmed breach.

PAPERWORK REDUCTION ACT 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 1845-0132. Public reporting burden for this collection of information is estimated to average 1 hour 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 a benefit (20 U.S.C. 1087e(h)). If you have comments or concerns regarding the status of
your individual submission of this application, please contact [email protected] directly.

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