1845-0058-False Cert Unauth 60D 20230618

60-DAY DRAFT 06/15/2023

OMB No. 1845-0058
Form Approved
Exp. Date 12/31/2023

LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION (UNAUTHORIZED SIGNATURE/PAYMENT)

William D. Ford Federal Direct Loan (Direct Loan) Program
Federal Family Education Loan (FFEL) 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: BORROWER IDENTIFICATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN ____________________

Name __________________________________________________

Address __________________________________________________

City __________________________________________________

State ____________________

Zip Code ____________________

Telephone – Primary ____________________________________

Telephone – Alternate ____________________________________

Email (Optional) ____________________________________

BEFORE YOU BEGIN

IMPORTANT: Use this application only if you believe that an employee of the school you identify in Item 4 of Section 2, or an affiliate of that school, forged your signature to receive a loan in your name.

if you believe that someone other than an employee of the school or an affiliate of the school forged your signature to receive a loan in your name, complete the “Loan Discharge Application: Forgery” form.

If you believe that your eligibility to receive a loan was falsely certified based on identity theft, complete the “Loan Discharge Application: False Certification (Identity Theft)” form.

Carefully read the entire application before completing it. Complete each item in Section 2 unless the item is identified as optional or the instructions tell you skip an item.

SECTION 2: UNAUTHORIZED SIGNATURE/PAYMENT INFORMATION

1. You are applying for this loan discharge as a:

Student borrower - Skip to Item 4.

Parent PLUS borrower - Continue to Item 2. If a question includes "(or the student)," answer as it applies to the student on whose behalf you borrowed the loan.

2. Student Name (Last, First, MI):

___________________________________________________________

3. Student SSN:

___________________________________________________________

4. School Name:

___________________________________________________________

School Address (Street, City, State, Zip Code):

5. Dates that you (or the student) attended the school identified in Item 4:

First Date: __________________	OR	Never Attended
Last Date: __________________		Don’t Know

6. Which documents were signed without your authorization?

Loan check

Loan application or promissory note

Master check or electronic funds transfer authorization

7. Did you (or the student) ever receive any money from the school, or did the school ever reduce the amount of money that you owed to the school?

Yes - Continue to Item 8.

No - Skip to Item 10.

Don't Know - Skip to Item 10.

8. On what date did the school return money or reduce the amount owed?

_______________________________________________________________

9. By what amount did the school return money or reduce the amount owed?

________________________________________________________________

10. How did you pay tuition and fees at the school?

11. Provide the name and position of the school employee or other person associated with the school who signed your name on the documents identified in Item 6.

Name: ________________________________________________________

Position: ________________________________________________________

OR Don't Know.

12. Provide any other information you have about the circumstances under which the person identified in Item 11 signed your name on the documents identified in Item 6 (completion of this item is optional):

SECTION 3: REFUNDS OR PAYMENTS

13. Have you (or the student) requested or received a refund or payment from the school or any third party (see Section 6) for any loan that you are requesting be discharged?

Yes - Continue to Item 14.

No - Skip to Item 17.

Don't Know - Skip to Item 17.

14. Provide the name, address, and telephone number of the organization you requested or received a payment from:

Name: ________________________________________________________________

Address (Street, City, State, Zip Code):

Telephone Number: ____________________________________________________

15. What is the amount and the status of the claim?

Amount: _____________________________________________________________

Status: _____________________________________________________________

18. What was the amount of any payment received? If none, enter "0."

___________________________________________________________________

19. Did the school refund any money on your behalf?

Yes - Continue to Item 18.

No - Sign and date the application in Section 4, then send it to the address in Section 8.

Don't Know - Sign and date the application in Section 4, then send it to the address in Section 8.

20. What was the amount of the refund?

___________________________________________________________________

21. Explain why the money was refunded:

SECTION 4: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION

I certify that:

• I am applying for a discharge of my loans because the documents identified in Section 2, Item 6 were not signed or authorized by me.

• I did not sign any of the documents I checked in Section 2, Item 6.

• I have read and agree to the terms and conditions for loan discharge, as specified in Section 7.

• Under penalty of perjury, all of the information I have provided on this application and in any accompanying documentation I may provide to support my eligibility for discharge (for example, documents containing samples of my signature) is true and accurate to the best of my knowledge and belief.

By signing this application, I assign and transfer to the U.S. Department of Education (the Department) any right I have to a refund on the amount discharged from the school and/or from any owners, affiliates, or assignees of the school, and from any third party that pays claims for a refund because of the actions of the school.

I authorize the organization I submit this request to and its agents to contact me regarding my request or my loans at the cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or prerecorded voice or text messages.

Borrower's Signature ________________________________________________

Date ________________________________________________

SECTION 5: INSTRUCTIONS FOR COMPLETING THE APPLICATION

When completing this application, type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only numbers. Example: March 14, 2024 = 03-14-2024. If you need more space to answer any of the items, continue on separate sheets of paper and attach them to this application. Identify the question number for which you are providing additional information. Include your name and Social Security Number (SSN) at the top of page 2 and on all attached pages. Return the completed application and documentation to the address shown in Section 8.

SECTION 6: DEFINITIONS

The William D. Ford Federal Direct Loan (Direct Loan) Program includes Federal Direct Stafford/Ford (Direct Subsidized) Loans, Federal Direct Unsubsidized Stafford/Ford (Direct Unsubsidized) Loans, Federal Direct PLUS (Direct PLUS) Loans, and Federal Direct Consolidation (Direct Consolidation) Loans.

The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans (both subsidized and unsubsidized), Federal Supplemental Loans for Students (SLS), Federal PLUS Loans, and Federal Consolidation Loans.

The holder of your Direct Loan Program loans is the Department. The holder of your FFEL Program loans may be a lender, a guaranty agency, or the Department. Your loan holder may use a servicer to handle billing and other communications related to your loans. References to “your loan holder” on this form mean either your loan holder or your servicer.

Unauthorized signature means that the school, without the borrower's authorization, signed the borrower's name on the loan application or promissory note.

Unauthorized payment means that the school, without the borrower's authorization, endorsed the borrower's loan check or signed the borrower's authorization for electronic funds transfer or master check, and did not give the loan proceeds to the borrower or apply the loan proceeds to charges owed by the student to the school.

If your loan is discharged, this means that you (and any endorser) are not required to repay the remaining portion of the loan, and you will be reimbursed for any payments on the loan that you made voluntarily or through forced collection (for example, through wage garnishment or Treasury offset). For a consolidation loan, only the portion that represents the original loans you received and that are eligible for discharge will be discharged. The loan holder reports the discharge to all consumer reporting agencies to which the holder previously reported the status of the loan and requests the removal of any adverse credit history previously associated with the loan.

The student refers to the student on whose behalf the parent borrower obtained a Direct PLUS Loan or Federal PLUS Loan.

Third party refers to any entity that may provide reimbursement for a refund owed by the school, such as a State or other entity offering a tuition recovery program.

SECTION 7: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION (UNAUTHORIZED SIGNATURE/PAYMENT)

You are eligible to have your loans discharged based on false certification (unauthorized signature/payment) if the school, without your authorization:

• Signed your name on the loan application or promissory note; or

• Endorsed the loan check or signed your authorization for electronic funds transfer, unless the proceeds of the loan were delivered to you (or the student) or applied to charges owed by the student to the school.

Only loans made on or after January 1, 1986 are eligible for this type of discharge.

By signing this application, you are agreeing to provide, upon request, testimony, a sworn statement, or other documentation reasonably available to you that demonstrates to the satisfaction of the Department or its designee that you meet the qualifications for loan discharge, or that supports any statement you made on this application or in any accompanying documents.

By signing this application, you are agreeing to cooperate with the Department or the Department's designee in any enforcement action related to this application.

Your application may be denied or your discharge may be revoked if you fail to provide testimony, a sworn statement, or documentation upon request, or if you provide testimony, a sworn statement, or documentation that does not support the material representations you made on this application or in any accompanying documents.

SECTION 8: WHERE TO SEND THE COMPLETED APPLICATION

Return the completed application and any documentation to: (If no address is shown, return to your loan holder.)

If you need help completing this application, call:
(If no telephone number is shown, call your loan holder.)

SECTION 9: 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. and §451 et seq. of the Higher Education Act of 1965, as amended (20 U.S.C. 1071 et seq. and 20 U.S.C. 1087a 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 Federal Family Education Loan (FFEL) Program or the William D. Ford Federal Direct Loan (Direct Loan) 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 FFEL and/or Direct Loan 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.

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 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 it displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0058. 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 information collection. The obligation to respond to this collection is required to obtain or retain a benefit (34 CFR 682.402(e)(3), or 685.215(c)). If you have comments or concerns regarding the status of your individual submission of this form, contact your loan holder directly.

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