Form 510

LENDER'S APPLICATION FOR INSURANCE CLAIM ON A FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL)

OMB Control Number 1845-0127 Expires Form Under Review

WARNING: Any person who knowingly makes a false statement or misrepresentation in a HEAL loan 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 possible fine and imprisonment under Federal Statue.

1a. Holder Information

Holder ID Number: ________________________________________________

Holder Name: ____________________________________________________

Address: ________________________________________________________

City/State/Zip Code:________________________________________________

Telephone No.: ___________________ Fax: ____________________________

1b. Servicer Information

Servicer ID Number: _______________________________________________

Servicer Name: ____________________________________________________

Address: __________________________________________________________

City/State/Zip Code:________________________________________________

Telephone No.: ____________________ Fax: _____________________

Original Claim Submission

Yes □ No □

If no, date on letter rejecting original claim submission:

1c. Claim Type

Judgment □

Bankruptcy Chapter 11 □

Bankruptcy Chapter 13 □

Bankruptcy Adversary □

Skip □

Unable to Serve □

Disability □

Death □

Low Loan □

Low Balance □

2. Borrower Information

Borrower Name (Last, First , M.I.)

Social Security No.

Last Known Address

City

State Or Country

Zip Code

3. Heal Loan Information and Documentation (Complete all columns for each loan listed.)

Loan ID Number

Original Loan Amount Guaranteed

Amount Disbursed

Promissory Note Original (Check for Yes)

Promissory Note Copy with Affidavit (Check for Yes)

Application Original (Check for Yes)

Application Copy (Check for Yes)

Repayment Schedule Copy (Check for Yes)

Repayment Schedule Affidavit (Check for Yes)

Payment History (Check for Yes)

Principal & Interest Worksheet (Check for Yes)

No. of Months in Deferment

No. of Months in Forbearance

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HEAL — 510 PAGE 1

Borrower Name (Last, First, M.I.)

Social Security No.

4. Claim Information

Borrower School Separation Date

Repayment Begin Date

Refinanced Loan? Yes □ No □

Most Recent Delinquency Date

Reported Credit Bureau Date

Due Diligence Letter 1 Date

Due Diligence Letter 2 Date

Due Diligence Letter 3 Date

Due Diligence Letter 4 Date

Prior Bankruptcy? Yes □ No □

PCA 90 Day Letter Date

PCA 120 Day Letter Date

PCA 150 Day Letter Date

Final Demand Date

5. Judgment Claim

Litigation Began Date

Litigation ID Number

Judgment Date

Judgment Assignment Date

Exemplified or Certified Judgment Received Date

Post-Judgment Interest Rate (Percent Only)

Continuing Interest Clause? Yes □ No □

6. Bankruptcy Claim (All Bankruptcy claims must be filed within 10 days of notification and include required documentation.)

Official Notification of Bankruptcy Date

First Meeting of Creditors Included? Yes □ No □

Proof of Claim Included? Yes □ No □

Transfer of Proof of Claim? Yes □ No □

Copy of Bankruptcy Plan Included? Yes □ No □

Adversary Only

Basis for Objection Included? Yes □ No □

Copy of Complaint? Yes □ No □

Complaint Date

Copy of Summons? Yes □ No □

Adversary Received Date

7. Skip

8. Unable to Serve

Skip Tracing Began Date

Determination Date

No. of Attempts to Serve

Was Service Attempted by Officers of the Court (Public Service)? Yes □ No □

Return of Service? Yes □ No □

Last Attempt Date

Copy of Complaint Included? Yes □ No □

9. Disability

Notified of Disability Date

Package Sent to ED Date

ED Approval Date

10. Death

Notified of Death Date

Official Notification of Death Received Date

11. Low Loan

All Loans Made Prior to 11/14/88 <$5000? Yes □ No □

All Loans Made on After 11/4/88 <$2500? Yes □ No □

12. Low Balance

Claim Amount <$1000? Yes □ No □

13. Total Amount of Insurance Claim (Principal and Interest): $__________________________ I certify that the information on this form is correct. I have used standard commercial collection practices and conformed to the due diligence standards of the HEAL regulations and policy guidelines. The borrower is not entitled to the deferment of principal, as provided in the Promissory Note(s). Any further payments by the borrower will be returned to the borrower.

FOR PSC USE ONLY

14a. Signature of Authorizing Official

14b. Name and Title (Please Print)

14c. Date

HEAL — 510 PAGE 2