Loan Discharge Applications (DL/FFEL/Perkins)

60-DAY DRAFT 06/15/2023

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

LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION (IDENTITY THEFT)

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: APPLICANT 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 ____________________

Driver’s License and State ________________________________________

Telephone – Primary ____________________________________

Telephone – Alternate ____________________________________

Email (Optional) ____________________________________

BEFORE YOU BEGIN

Use this form if you believe that a loan in your name was falsely certified as the result of the crime of identity theft (see Section 4 for the definition of “identity theft”). 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: IDENTITY THEFT 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 the loan was made.

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

3. Student SSN:

4. Provide the information requested below for each loan in your name that you believe was falsely certified due to the crime of identity theft. To find information about these loans, visit StudentAid.gov/login or call 1-800-4-FED-AID. Attach additional pages if necessary.

Loan Amount	Loan Date	School Name	School Address (Street, City, State, Zip Code)

5. Did you apply for the loans that you want discharged?

Yes – You are not eligible for this discharge.

No

6. How and when did you become aware that the loans you want discharged were made in your name without your authorization? Explain in detail below.

7. Did you (or the student) receive a refund in cash, check, or electronic funds transfer from the loan, was the loan applied to your (or the student's) account at a school you attended, or did you (or the student) benefit in any other way from the loans you want discharged?

Yes – Explain below how and when the benefits of the loan were provided.

No

8. Did you sign a promissory note, in ink or electronically, for the loans you want discharged?

Yes

No

9. Have you (or the student) ever attended a postsecondary school (a college, university, or other school after high school)?

Yes – Continue to Items 10 and 11.

No – Skip to Item 12.

10. Provide the requested information concerning the postsecondary school(s) that you (or the student) attended, then continue to Item 11.

School Name	Dates of Attendance	Online Program?
		Yes No
		Yes No

11. How did you (or the student) pay for the cost of attendance at the school(s) listed in Item 10? Explain below and attach documentation to show how you paid for the cost of attendance (for example, receipts issued by the school or negotiated personal checks).

12. Explain in detail below how you believe your identity was used without your authorization to make the loans you want discharged. Attach additional pages if needed.

13. Check the appropriate box(es) below to identify the type of supporting evidence you are providing to show that your eligibility for the loans you want discharged were falsely certified as a result of identity theft committed against you. Check all that apply. You must attach a copy of each type of evidence that you identify.

Judicial (court) determination of identity theft committed against you.

Federal Trade Commission identity theft affidavit.

Police report alleging identity theft committed against you.

Documentation of a dispute of the validity of the loan due to identity theft filed with at least three major consumer reporting agencies (credit bureaus).

Other evidence. Describe the other evidence in detail below and attach a copy of the evidence. Other evidence may include, but is not limited to, documents showing your actual signature (for example, cancelled checks, signed tax returns, driver’s license) or documents showing proof of your address at the time the loans you want discharged were made (for example, a lease or utility bill).

14. Provide the address(es) where you were residing at the time the loans you want to have discharge were originated or certified and your dates of residence at each address.

Address (Street, City, State, Zip Code)	Dates of Residence

SECTION 3: APPLICANT CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION

I certify that:

• I have read and agree to the terms and conditions for loan discharge, as specified in Section 5.

• Under penalty of perjury, all of the information I have provided on this application and in any accompanying documentation 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.

Applicant’s Signature ________________________________________________

Date ________________________________________________

SECTION 4: 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.

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 a parent borrower obtained a Direct PLUS Loan or Federal PLUS Loan.

For purposes of this form, identity theft means the unauthorized use of the identifying information (see below) of another individual that is punishable under 18 U.S.C. 1028, 1028A, 1029, or 1030, or substantially comparable state or local law.

Identifying information includes, but is not limited to, the following:

• Name

• Social Security Number

• Date of birth

• Official state or government issued driver’s license or identification number

• Alien registration number

• Government passport number

• Employer or taxpayer identification number

• Unique biometric information (for example, fingerprints, voiceprint, retina or iris image) or unique physical representation

• Unique electronic identification number, address, or routing code

• Telecommunication identifying information or access device (as defined in 18 U.S.C 1029(e))

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 5: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION (IDENTITY THEFT)

You are eligible to have your loans discharged based on false certification (identity theft) if a school falsely certified your eligibility to receive a loan as a result of the crime of identity theft committed against you.

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 6: 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, 2023 = 03-14-2023. 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 pages [TBD] and on any attached pages. Return the completed application and documentation to the address shown in Section 7.

SECTION 7: 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 8: 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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