1845-0065_TPD Rep_30D_2023-11-16

TPD-REP

APPLICANT REPRESENTATIVE DESIGNATION: TOTAL AND PERMANENT DISABILITY 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.

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

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		Zip Code
Phone - Primary
Phone - Alternate
Email

.

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

SECTION 4: WHERE TO SEND THE COMPLETED DISCHARGE APPLICATION

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

If you need help completing this form, contact us: Phone: 1-888-303-7818 (TTY: dial 771, then phone no.) Email: [email protected] Website: www.disabilitydischarge.com

SECTION 5: IMPORTANT NOTICES

Privacy Act Statement

Authority: The authorities for collecting the requested information from and about you are §421 et seq., §451 et seq., §461, and §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).

Purpose: The principal purposes for collecting the information on the Discharge Application: Total and Permanent Disability, including your Social Security Number (SSN), are to verify your identity, to determine your eligibility to receive a loan or TEACH Grant or a benefit on a loan or TEACH Grant (such as a deferment, forbearance, discharge, or forgiveness) under the William D. Ford Federal Direct Loan (Direct Loan), Federal Family Education Loan (FFEL), Federal Perkins Loan (Perkins Loan), or Teacher Education Assistance for College and Higher Education (TEACH_ Grant programs, to permit the servicing of your loans, to enforce the conditions or terms of a title IV, HEA obligation, to originate, disburse, service, collect, assign, adjust, transfer, refer, furnish credit information for, and discharge a title IV, HEA obligation, to verify whether a title IV, HEA obligation qualifies for discharge, to determine credit balances to be refunded by the U.S. Department of the Treasury (Treasury) to the individual or loan holder, 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.

Disclosures: The information provided on the Discharge Application: Total and Permanent Disability form will only be disclosed outside of the U.S. Department of Education (Department) with prior written consent or as otherwise allowed by the Privacy Act of 1974, as amended (Privacy Act) (5 U.S.C. 552a). One of the exceptions to the Privacy Act’s prior written consent requirement that allows for disclosure, without consent, is for “routine uses” that the Department publishes in our System of Records Notices (SORNs). The Department may disclose, without consent, the information provided on a Discharge Application: Total and Permanent Disability form, on a case-by-case basis or under a computer matching program, to third parties pursuant to the routine uses identified in the “Common Services for Borrowers (CSB) System” (18-11-16) SORN. This notice is available on the Department’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.

These routine uses included, but are not limited to:

• To verify the identity of the individual who records indicate has applied for or received title IV, HEA program funds, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, Tribal, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; to adjudicative bodies; and to the individual whom the records identify as the party obligated to repay the title IV, HEA obligation;

• To determine program eligibility and benefits, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To enforce the conditions or terms of a title IV, HEA obligation, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; to adjudicative bodies; and to the individual whom the records identify as the party obligated to repay the title IV, HEA obligation;

• To permit originating, disbursing, servicing, collecting, assigning, adjusting, transferring, referring, furnishing of credit information, or discharging title IV, HEA obligations, disclosures may be made to guaranty agencies, educational institutions, or financial institutions that originated, held, serviced, or have been assigned the title IV, HEA obligation, and their authorized representatives; to a party identified by the debtor as willing to advance funds to repay the title IV, HEA obligation; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To investigate possible fraud or abuse or to verify compliance with contractual requirements or Federal, State, local, or Tribal statutory, regulatory, or program requirements, disclosures may be made to guaranty agencies, educational and financial institutions, third-party servicers, and their authorized representatives; to Federal, State, Tribal, or local agencies, and their authorized representatives; to private parties, such as relatives, present and former employers, and business and personal associates; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To locate a delinquent or defaulted borrower, or an individual who owes a title IV, HEA obligation, disclosures may be made to guaranty agencies,

• To verify whether a title IV, HEA obligation qualifies for discharge, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, present and former employers, and business and personal associates; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To prepare a title IV, HEA obligation for litigation, to provide support services for litigation on a title IV, HEA obligation, to litigate a title IV, HEA obligation, or to audit the results of litigation on a title IV, HEA obligation, disclosures may be made to FFEL loan holders or servicers; Department contractors including but not limited to, Federal Loan Servicers, NFP Federal Loan Servicers, the Federal Perkins Servicer, PCAs and to guaranty agencies and their authorized representatives; Federal, State, Tribal, or local agencies, and their authorized representatives; and to adjudicative bodies.

For additional routine uses, view the “Common Services for Borrowers (CSB) System” (18-11-16) SORN. This notice is available on the Department’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.

Consequences of Failure to Provide Information: Participating in the Direct Loan Program, the FFEL Program, the Perkins Loan Program, or the TEACH Grant Program and giving us your SSN are voluntary, but providing the Department your SSN and the requested information is mandatory to participate.

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 4).

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