Income Verification Paper-Based Form

OMB #

Paper Form Version

Student Loan Debt Relief Income Verification

To process your (or your child’s) Federal Student Loan Debt Relief Application, we need you to verify that your income meets the eligibility requirements for debt relief. The deadline to submit documentation is March 31, 2024.

Only complete this form if you’ve been notified by the U.S. Department of Education that you need to submit income verification for your Student Loan Debt Relief Application.

Eligibility for Loan Debt Relief

Who qualifies for Student Loan Debt Relief?

• Individuals who made less than $125,000 in 2020 or 2021

• Families that made less than $250,000 in 2020 or 2021

If you filed federal taxes, your income requirements are based on your adjusted gross income (AGI), which tends to be lower than your total income. Your AGI can be found on line 11 of the IRS Form 1040.

Submit Your Income Documentation

To verify your income, you must attach ONE of the following documents:

• IRS Form 1040 (tax return) from 2020 or 2021

• IRS Tax Return Transcript from 2020 or 2021

• Verification of non-filing letter from 2020 or 2021 (if you didn’t file federal taxes)

Borrower Information:  

First Name___________________

Middle Initial (optional): ____ 

Last Name: ________________  

Former Last Name _________________________ 

Social Security Number (SSN):  _____________________ 

Date of Birth (mm-dd-yyyy):  _______________ 

Address:  ______________________________________  

City (and Country if not U.S.):  ____________   State:  ___   ZIP Code:  _________  

Phone Number: ________ ______________________ 

Email: _____________________________________ 

Submit Income Documentation

To verify your income, attach ONE of the following documents to this form.

Which document are you attaching? (select one)

[ ] IRS Form 1040 (tax return) from 2020 or 2021

[ ] IRS Tax Return Transcript from 2020 or 2021

[ ] Verification of non-filing letter from 2020 or 2021

Tax Year (select one)

[ ] 2020

[ ] 2021

Tax Filing Status (select one)

[ ] Single

[ ] Married filing jointly

[ ] Married filing separately

[ ] Head of Household

[ ] Qualifying Widow(er)

[ ] I certify under penalty of perjury under the laws of the United States of America that all of the information provided on this form, or on any accompanying document, is true and correct. I understand that any falsification 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, including, but not limited to, under 18 U.S.C. § 1001, 18 U.S.C. § 1621, and 20 U.S.C. § 1097.

Signature: ____________________________ Date: _______________  

WHERE TO SEND THE COMPLETED FORM

Return the completed form and any documentation to: 

Federal Student Aid Information Center

PO Box 1854

Monticello, KY 42633

Fax to: (606) 396-4821

Privacy Act Statement  

The Privacy Act of 1974, as amended (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 via this form are title IV of the Higher Education Act of 1965, as amended (HEA) (20 U.S.C. 1070 et seq.); 20 U.S.C. 1018(f) and 1087e(h); the Higher Education Relief Opportunities for Students Act of 2003 (20 U.S.C. 1098bb) (including any waivers or modifications that the Secretary of Education deems necessary to make to any statutory or regulatory provision applicable to the federal student financial assistance programs under title IV of the HEA to achieve specific purposes listed in the section in connection with a war, other military operation, or a national emergency); the Presidential Memorandum entitled, “A Student Aid Bill of Rights to Help Ensure Affordable Loan Repayment” (March 10, 2015); and 31 U.S.C. 7701 and Executive Order 9397, as amended by Executive Order 13478 (November 18, 2008). 

Participating in the Federal Student Loan Relief is voluntary, but you must provide your SSN and enough of the other requested information on this form so that the U.S. Department of Education (Department) can verify your identity in order 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 loan relief, and to permit the servicing of your loans. Failure to provide any of the requested information may result in your application for Federal Student Loan Relief not being processed. 

The requested information on this form also may be disclosed without your consent, on a case-by-case basis or under a matching program, to third parties as authorized under routine uses set forth in the system of records notices entitled, “Common Services for Borrowers (CSB)” (18-11-16) and “Enterprise Data Management and Analytics Platform Services (EDMAPS)” (18-11-22). All published systems of records notices are available under the “Department System of Records Notice”/“Federal Student Aid (FSA)” subsection of the U.S. Department of Education’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html. A summary of some of the routine uses in these system of records notices are set forth below.

To assist with the determination of eligibility for loan discharges, the Department may disclose records to holders of loans made under title IV of the HEA. To verify the identity of the individual whom records indicate has applied for or received title IV, HEA program funds, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, Tribal, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; to adjudicative bodies; and to the individual whom the records identify as the party obligated to repay the title IV, HEA obligation;

To determine program eligibility and benefits, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; and to adjudicative bodies.

In the event of judicial or administrative litigation or Alternative Dispute Resolution (ADR), we may send the requested information on this form to the Department of Justice, an adjudicative body, counsel, representative, party, or witness if the disclosure is relevant and necessary to the judicial or administrative litigation or ADR. If the requested information on this form indicates, either alone or in connection with other information, a violation or potential violation of any applicable statutory, regulatory, or legally binding requirement, we may send it to an entity charged with the responsibility for investigating or enforcing those violations or potential violations. We may send the requested information on this form to a Member of Congress or the Member’s staff when necessary to respond to an inquiry from the Member that was made at your written request and on your behalf. Disclosure of the requested information on this form may be made to our contractors for the purpose of performing any function that requires disclosure including for the purpose of Federal Student Loan Relief. As part of any contract with any such contractor, we shall require the contractor to agree to establish and maintain safeguards to protect the security and confidentiality of the disclosed information. Disclosures may also be made to certain researchers under certain circumstances including the researchers agreeing to establish and maintain safeguards to protect the security and confidentiality of the disclosed information.

Further, if the requested information on this form is shared with other principal offices of the U.S. Department of Education that have a need for it in the performance of their job duties, such as the Office of Inspector General, then it may be shared with third parties as authorized under routine uses set forth in such office’s system of records notices, such as the “Investigative Files of the Inspector General” (18-10-01).

Paperwork 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-XXXX. Public reporting burden for this collection of information is estimated to average 35 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 voluntary. If you have comments or concerns regarding the status of your individual submission of this form, please contact Federal Student Aid Information Center, P.O. Box 84, Washington, D.C. 20044 directly. Note: Please do not return the completed form to this address.