Direct Loan, FFEL, Perkins and TEACH Grant Total and Permanent Disability Discharge Application and Related Forms

APPLICANT REPRESENTATIVE DESIGNATION: TOTAL
AND PERMANENT DISABILITY
TPD-REP

OMB No. 1845-0065
FORM UNDER REVIEW
Exp. Date XX/XX/XXXX

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan)
Program / TEACH Grant Program

WARNING: Any person who knowingly makes a false statement 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 and 20 U.S.C. 1097.
SECTION 1: DISCHARGE APPLICANT INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Date of Birth
Name
Address
City

State

Zip Code

Telephone - Primary
Telephone - Alternate
Email
SECTION 2: DESIGNATION, CHANGE, OR REVOCATION OF APPLICANT REPRESENTATIVE
This form is required to designate an individual or organization to represent you in matters related to your total and permanent disability discharge
request, even if that individual or organization already has authority to act on your behalf, for example, through a power of attorney. Before
completing this form, carefully read the entire form, particularly Section 3. Type or print using dark ink. Return this form to the address shown in
Section 4.
1. Why are you completing this form?
I am designating an individual or organization to represent me in all matters relating to my total and permanent disability request Continue to Item 2.
I am changing the individual or organization that represents me in all matters relating to my total and permanent disability request Continue to Item 2.
I am revoking my previous designation of an individual or organization that represents me in all matters related to my total and permanent
2. Please provide contact information for the representative that you are designating. If you are designating an organization, you do not need to
provide a name of an individual at the organization that will be your representative. However, you must provide a Taxpayer ID Number.
Individual Name
Organization Name
Organization Taxpayer ID Number
Address
City

State

Telephone - Primary
Telephone - Alternate

.

Email

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Zip Code

Applicant Name _________________________________________________________

Applicant SSN ____________________________

SECTION 3: APPLICANT’S REQUEST, UNDERSTANDINGS, AUTHORIZATION, AND CERTIFICATION
I request to designate, change, or revoke an individual or organization to represent me in all matters related to my total and permanent disability
discharge request. If I have not already submitted an application for total and permanent disability discharge, I intend to do so.
I understand that:
1. The individual or organization that I designate in Section 2 will have the ability to receive information about my total and permanent disability
discharge request for my federal student loans or TEACH Grants that is otherwise protected by the Privacy Act of 1974 and will have the ability to
act on my behalf as it relates to my total and permanent disability discharge request, including the authority to apply for a discharge, provide
notifications or information to the U.S. Department of Education (the Department), and receive notifications and correspondence from the
Department.
2. To verify my representative's identity when making a request for disclosure or providing information by telephone, the representative may be
required to provide my name, Social Security Number, and date of birth.
3. When requesting the disclosure of information, the representative named in Section 2 must submit information to verify his or her identity or
the organization for which he or she works.
4. If I am requesting to change or revoke the individual or organization that represents me, the individual or organization that I previously
designated will no longer be my representative as of the date that the Department receives my request.
5. If I am requesting to revoke the individual or organization that represents me, I may do so in any oral or written communication to the
Department.
6. My representative may also revoke my designation in any oral or written communication to the Department; and
7. My designation, change, or revocation will be effective on the date that the Department receives and (if written) processes my communication.
I authorize the Department and its agents to release to, and discuss with, the individual or organization named in Section 2, any records held by the
Department regarding my federal student loan or TEACH Grant service obligation(s) and to send correspondence related to my discharge request
to that individual or organization. I also authorize the individual or organization named in Section 2 to assist me in satisfying the obligation through
a total and permanent disability discharge.
I certify that all of the information I have provided on this form and in any accompanying documentation is true, complete, and correct to the best
of my knowledge and belief.

Applicant's Signature

Date

Representative's Signature

Date

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SECTION 4: WHERE TO SEND THE COMPLETED DISCHARGE APPLICATION
Return the completed form and any documentation to:

If you need help completing this form, contact us:

U.S. Department of Education - TPD Servicing
P.O. Box 87130
Lincoln, NE 68501-7130
Fax to: 303-696-5250
Email to: [email protected]

Phone: 1-888-303-7818 (TTY: dial 771, then phone no.)
Email: [email protected]
Website: www.disabilitydischarge.com

SECTION 5: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (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 are §421 et seq., §451 et seq., §461, or §420L of the Higher
Education Act of 1965, as amended (20 U.S.C. 1071 et seq., 20 U.S.C.
1087a et seq., 20 U.S.C. 1087aa et seq., or 20 U.S.C. 1070g et seq.) and
the authorities for collecting and using your Social Security Number
(SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and
1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Direct Loan, FFEL,
Perkins Loan, or TEACH Grant program and giving us your SSN are
voluntary, but you must provide the requested information, including
your SSN, 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 a loan or a benefit on a loan (such as a deferment,
forbearance, discharge, or forgiveness) under the Direct Loan, FFEL,
Federal Perkins Loan or TEACH Grant Programs, to permit the servicing
of your loans, and, if it becomes necessary, to locate you and to collect
and report on your loans if your loans become delinquent or default.
We also use your SSN as an account identifier and to permit you to
access your account information electronically.
The information in your file may be disclosed, on a case-by-case basis
or under a computer matching program, to third parties as authorized
under routine uses in the appropriate systems of records notices. The
routine uses of this information include, but are not limited to, its
disclosure to federal, state, or local agencies, to private parties such as
relatives, present and former employers, business and personal
associates, to consumer reporting agencies, to financial and
educational institutions, and to guaranty agencies in order to verify
your identity, to determine your eligibility to receive a loan or a benefit
on a loan, to permit the servicing or collection of your loans, to enforce
the terms of the loans, to investigate possible fraud and to verify
compliance with federal student financial aid program regulations, or
to locate you if you become delinquent in your loan payments or if you
default. To provide default rate calculations, disclosures may be made
to guaranty agencies, to financial and educational institutions, or to
state agencies. To provide financial aid history information, disclosures
may be made to educational institutions.

made to guaranty agencies or to financial and educational institutions.
To counsel you in repayment efforts, disclosures may be made to
guaranty agencies, to financial and educational institutions, or to
federal, state, or local agencies.
In the event of litigation, we may send records to the Department of
Justice, a court, adjudicative body, counsel, party, or witness if the
disclosure is relevant and necessary to the litigation. If this information,
either alone or with other information, indicates a potential violation of
law, we may send it to the appropriate authority for action. We may
send information to members of Congress if you ask them to help you
with federal student aid questions. In circumstances involving
employment complaints, grievances, or disciplinary actions, we may
disclose relevant records to adjudicate or investigate the issues. If
provided for by a collective bargaining agreement, we may disclose
records to a labor organization recognized under 5 U.S.C. Chapter 71.
Disclosures may be made to our contractors for the purpose of
performing any programmatic function that requires disclosure of
records. Before making any such disclosure, we will require the
contractor to maintain Privacy Act safeguards. Disclosures may also be
made to qualified researchers under Privacy Act safeguards.

Paperwork Reduction 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 1845-0065. 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 a benefit in accordance with 34 CFR 674.61(b) or (c),
34 CFR 682.402(c)(2) or (c)(9), 34 CFR 685.213(b) or (c), and 34 CFR
686.42(b). If you have comments or concerns regarding the status of
your individual submission of this form, please contact the U.S.
Department of Education directly (see Section 6).

To assist program administrators with tracking refunds and
cancellations, disclosures may be made to guaranty agencies, to
financial and educational institutions, or to federal or state agencies. To
provide a standardized method for educational institutions to
efficiently submit student enrollment statuses, disclosures may be
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