502-1

OMB No 1845-0126
Exp. Date xx-xx-xxxx

REPAYMENT SCHEDULE (VARIABLE RATE) for the
Federal Health Education Assistance Loan (HEAL) Program
U.S. Department of Education

______________________________________________________________________________________________________________________________
PRA 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 1845-0126. 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 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 comment
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 as part of your disclosure of the Truth-inLending requirements of the Federal Reserve Board
(Regulation Z). The form shows the cost of the HEAL loan to
the borrower, and the number and amount of payments at the
time the form is completed by the lender.

Itemization of the Amount Financed

Getting ready to prepare this form

$

25,000

The following documents will assist you in completing the
repayment schedule:

$

5,000

• HEAL Regulations (34 CFR Part 681)

Amount paid to others on your behalf

• Copy of the borrower's application(s)
• Original Promissory Note(s)
• Amortization Schedules
• Lender/School Manual
• Federal Reserve System Regulation Z (Truth-In-Lending)

and Official Staff Commentary.

If your bank provided all the loan funds for the amount
financed, complete the itemization of the “Amount
Financed” as shown in the example below:
Itemization of the Amount Financed of $
30,000
Amount given to you directly
Amount paid on your account

$

0

to

$

0

to

If a portion of the amount financed includes HEAL
loans purchased from another lender, complete
the Itemization of the Amount Financed as shown below:
Itemization of the Amount Financed of $

INSTRUCTIONS
Borrower's Name and Social Security Number (SSN)
If the borrower's name has changed since the Promissory
Note(s) was signed, fill in the former name in parenthesis.
Jones (Smith), Mary A.

HEAL 502-1

50,000

$

25,000

Amount given to you directly

$

5,000

Amount paid on your account

Amount paid to others on your behalf
$
10,000 to National Bank of Fairfax
$

10,000

Coopersburg National Bank

When Payments are Due
The date the first payment is due must be stated.

PRIVACY ACT NOTIFICATION STATEMENT
The Privacy Act of 1974 (5 U.S.C. 552a) requires that an
agency provide the following notification to each individual
whom it asks to supply information. The following information is
contained in the system of records 18-11-20 entitled "Health
Education Assistance Loan Program."
1. The authority for collecting the requested information is
found in Title VII, Part A, Subpart I of the Public Health
Service Act (42 U.S.C. 292-292o) and the Consolidate
Appropriations Act, 2014.
2. The principal purposes of this information are as follows:
to verify the identity of the applicant; to determine
program eligibility and benefits; to permit servicing of the
loan; and in the event it is necessary, to locate missing
borrowers and collect on delinquent or defaulted
loans.
3. The routine uses include the following: the information
may be furnished during the life of the loan to holders of
this and other loans made to the borrower under the
HEAL Program; to educational institutions in which the
borrower is enrolled or is accepted for enrollment; to
guarantee agencies; to contractors which assist the
Department of Education in the administration of the
HEAL Program; to Federal or State agencies or private
parties who may be able to provide information
necessary for the collection of the loan or to assist in
the servicing or collection of the loan. Disclosures may
also be made to consumer reporting agencies in order to
aid in the collection of outstanding debts owed to the
Federal Government. Disclosure of records will consist
of the individual's name, social security number, and
other information necessary to establish the identity
of the individual, the amount, status, and history of the
claim, and the agency or program under which the
claim arose.
Section 3(c) of the Privacy Act (5 U.S.C. 552a) requires that
an agency keep an accounting of disclosures of individually
identified information from a system of records to all third
parties outside of the Department of Education. Upon an
individual's written request to the System Manager, an
agency must make the accounting of such disclosures
available to the subject individual.
Section 7(b) of the Privacy Act of 1974 (5 U.S.C. 552a) requires
that where any Federal, State, or local government agency
requests an individual to disclose his or her social security
account number (SSN), that the individual

HEAL 502-1

OMB No 1845-0126
Exp. Date xx-xx-xxxx

must also be advised whether that disclosure is mandatory or
voluntary, by what statutory or other authority the SSN is
solicited, and what uses will be made of it.

Disclosure of the applicant's SSN is mandatory for participation
in the HEAL Program as provided for by Section 4 of the Debt
Collection Act of 1982 (26 U.S.C. 6103 note). Applicants are
advised that failure to provide his/her SSN will result in the
denial of the individual to participate in the HEAL Program.
The SSN will be used to verify the identity of the applicant and
as an account number (identifier) throughout the life of the loan
to record necessary data accurately. As an identifier, the SSN
is used in such program activities as: determining program
eligibility; certifying school attendance and student status;
determining eligibility for deferment of repayment;
determining eligibility for disability or death claims, and for
tracing and collecting in cases of delinquent or defaulted loans.
FINANCIAL PRIVACY ACT
Under the Right to Financial Privacy Act of 1978 (12 U.S.C.
3401-3412), the U.S. Department of Education will have
access to financial records in your student loan file maintained
by the Lender in connection with the administration of the
HEAL Program

OMB No 1845-0126
Exp. Date xx-xx-xxxx

DEPARTMENT OF EDUCATION
Federal Student Aid

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN PROGRAM
(42 U.S.C. 292-292o and the Consolidated Appropriations Act, 2014)
Repayment Schedule (Variable Rate)
Borrower’s Name & SSN

Holder’s Name

Address
State

Zip Code

City

Address

Area Code/Telephone Number
(
)

State

ANNUAL
PERCENTAGE
RATE

%
Your payment schedule will be:
Number of Payments

Zip Code

Area Code/Telephone Number
(
)

FINANCE
CHARGE

Amount
Financed

Total of
Payments

$

$

$

Amount of Payments

When Payments are Due (see instructions)

The dollar amount
the credit will cost
you.

The cost of your credit
as a yearly rate.

City

The ANNUAL PERCENTAGE RATE may increase during the term of this
transaction. If the index to the average of the bond equivalent rates reported
for ninety-one day U.S. Treasury Bills auctioned during the preceding quarter
increases as determined by the interest calculation formula. The rate will not
increase more than every calendar quarter. Any increase will take the form of
higher periodic payments, more payments of the same amount, or a large
amount due at maturity. If your loan was for $_______________________ at
_________________% for__________________ years and the rate
increased to _________________% after the 3rd payment, your periodic
payments would increase by $_____________________.

This Repayment Schedule consolidates ___________________ promissory
Notes.
Itemization of the Amount Financed $___________________________
$_______________Amount given to you directly
$_______________Amount paid on your account
Amount paid to others on your behalf

The amount of credit
provided to you or on
your behalf.

The amount you will
have paid after you
have made all payments
as scheduled.

Late Charge: If payment is late you will be charged 5 cents for each
dollar of the installment payment due.
See your Promissory Note for any additional information about
Nonpayment, default, any required repayment in full before the
Scheduled date, and prepayment penalties.
Prepayment: If you pay off early, you will not have to pay a penalty.

The ANNUAL PERCENTAGE RATE is a variable rate, subject to increase
or decrease. The rate will increase if the average of the bond equivalent
rate increases. The amount disclosed in the above schedule is the APR in
effect at the time this repayment schedule was prepared. If the rate
increases, you would have to make more payments of the same amount, or
owe a larger amount at maturity. If the rate decreases, the principal balance
of the loan will be reduced more quickly, and the final payment(s) may be
reduced more quickly, and the final payment(s) may be reduced or
eliminated.

$_______________ to
$_______________ to

WARNING:

HEAL 502-1

(Date form completed by lender)

Any person 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 commits any other illegal action in
connection with a HEAL loan is subject to a fine or imprisonment under Federal statute.