1845-0163 Affidavit for Institutional Response

OMB Number: 1845-0163

Form Approved

Expiration Date: 11/30/2023

U.S. DEPARTMENT OF EDUCATION

BORROWER DEFENSE TO REPAYMENT

AFFIDAVIT FOR INSTITUTIONAL RESPONSE

Under 34 C.F.R. §685.405(c), the Institution must submit an affidavit, on a form approved by the Secretary, certifying under penalty of perjury that the information submitted to the U.S. Department of Education in response to borrower defense applications submitted by Federal student loan borrowers is true and correct.

I, _____[typed name]_________________________, pursuant to 28 U.S.C. § 1746, declare that:

1. I am employed by ___[school]____________________ as __[title]_________________ .

2. By reason of my position I am authorized and qualified to certify that information and any documentation submitted with this affidavit is true and correct.

3. The information submitted to the U.S. Department of Education in responding to borrower defense applications by Federal student loan borrowers is true and correct.

4. At the request of the U.S. Department of Education, I will provide additional information or documentation as needed to verify that the information I am providing is true and correct.

I certify under penalty of perjury that the foregoing is true and correct. Executed on __[date]_________________.

__________________________
Signature

Enclosures:

Department Notice to Institution