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

TPD-APP

DISCHARGE APPLICATION: TOTAL AND PERMANENT DISABILITY Direct Loan Program / FFEL Program / Perkins Loan Program TEACH Grant Program

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

General Information

Total and permanent disability (TPD) discharge

This is an application for a TPD discharge of federal student loans you received under the William D. Ford Federal Direct Loan Program (Direct Loan Program), the Federal Family Education Loan Program (FFEL Program), or the Federal Perkins Loan Program (Perkins Loan Program), and/or your Teacher Education Assistance for College and Higher Education Grant Program (TEACH Grant Program) service obligation.

The Direct Loan Program includes Direct Subsidized Loans, Direct Unsubsidized Loans, Direct PLUS Loans, and Direct Consolidation Loans.

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

The Perkins Loan Program includes Federal Perkins Loans, National Direct Student Loans (NDSL), and National Defense Student Loans (Defense Loans).

The TEACH Grant Program requires individuals to complete a teaching service obligation as a condition for receiving a TEACH Grant.

If you receive a TPD discharge of a loan, this means that you do not have to repay the remaining balance of the loan. If you receive a TPD discharge of a Direct PLUS Loan or Federal PLUS Loan that you obtained with an endorser (an endorser is someone who agrees to repay a PLUS loan if the borrower does not repay it), the discharge also cancels the endorser’s obligation to repay the loan.

If you receive a TPD discharge of a TEACH Grant service obligation, this means that you are no longer required to complete the teaching service that you agreed to perform as a condition for receiving a TEACH Grant.

Requirements to qualify for TPD discharge

To qualify for TPD discharge, you must have a total and permanent disability. You are considered to have a total and permanent disability if:

1. You are a veteran who has been determined by the VA to be unemployable due to a service-connected disability; or

2. You are unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that can be expected to result in death, or that has lasted for a continuous period of not less than 60 months, or that can be expected to last for a continuous period of not less than 60 months.

To show that you have a total and permanent disability, you must submit certain documentation from one of the following sources:

1. The U.S. Department of Veterans Affairs (VA);

2. The Social Security Administration (SSA); or

3. Certain licensed or certified medical professionals.

The specific types of documentation you must provide are explained in Sections 6 and 7. Except for VA or SSA determinations as described in Sections 6 and 7, a disability determination by another federal or state agency does not qualify you for this discharge.

Note: If you qualify for TPD discharge by providing documentation from the VA or the SSA, you are not required to have a medical professional complete Section 4 of this application.

Important tax information

Loan amounts discharged due to TPD are not considered taxable income by the Internal Revenue Service (IRS) for federal tax purposes. However, some states may consider the discharged loan amount to be income for state tax purposes. If you receive a TPD discharge of a loan, check with your state tax office or a tax professional before filing your state tax return.

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 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
	Phone - Primary
	Phone - Alternate
	Email

SECTION 2: TOTAL AND PERMANENT DISABILITY INFORMATION

Carefully read the entire application before you complete this section. Sign and date the application in Section 3.

1. Are you a veteran who has received a determination from the U.S. Department of Veterans Affairs (VA) that (A) you have a service-connected disability (or disabilities) that is 100% disabling, or (B) you are totally disabled based on an individual unemployability rating?

Yes - Attach documentation of the VA determination and complete Section 3. Send pages 2 and 3 with the required VA documentation to the address shown in Section 3. You do not need to have an authorized medical professional complete Section 4.

No - Continue to Question 2.

2. Are you currently receiving SSDI or SSI benefits, or SSA retirement benefits, and does your most recent SSA notice of award, SSA Benefits Planning Query (BPQY), or other documentation show that you meet one of the requirements A through E listed below?

1. You qualify for SSDI or SSI based on disability, and your next scheduled disability review is between 5 and 7 years from the date of your last SSA disability determination;

2. You qualify for SSDI or SSI based on disability and your next continuing disability review has been scheduled at 3 years;

3. You have an established onset date for SSDI or SSI of at least 5 years before the date of your application for TPD discharge, or you have been receiving SSDI or SSI based on disability for at least 5 years before the date of your application for TPD discharge;

4. You qualify for SSDI or SSI based on a compassionate allowance; or

5. You are currently receiving SSA retirement benefits, and before you qualified for SSA retirement benefits, you met one of the requirements described in paragraphs A through D above.

Yes - Attach a copy of your most recent SSA notice of award or BPQY, or other documentation showing that you meet one of the requirements listed above and complete Section 3. If you submit documentation other than a notice of award or BPQY it will be accepted only if it provides sufficient information to determine that you meet the requirements above. Send pages 2 and 3 with the required SSA documentation to the address shown in Section 3. You do not need to have an authorized medical professional complete Section 4.

No – Complete Section 3 and have an authorized medical professional complete and sign Section 4. Enter your name and Social Security Number at the top of page 4. Send pages 2 through 5 to the address shown in Section 3.

SECTION 3: REQUEST FOR DISCHARGE, AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS

I request that the U.S. Department of Education discharge my Direct Loan, FFEL, and/or Perkins Loan program loan(s), and/or my TEACH Grant service obligation.

I authorize any authorized medical professional (as defined in Section 7), hospital, or other institution having records about the disability that is the basis for my request for a discharge to make information from those records available to the U.S. Department of Education.

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.

I understand that:

1. if I am applying for a discharge based on an authorized medical professional’s certification in Section 4, I must submit this application to the U.S. Department of Education within 90 days of the date of the authorized medical professional’s signature in Section 4; and

2. If I am a veteran who answered No to Questions 1 and 2 in Section 2, and I am applying for TPD discharge based on a certification from an authorized medical professional in Section 4, that certification is only for purposes of determining my eligibility for a discharge of my loans or TEACH Grant service obligation, and is not for purposes of determining my eligibility for, or the extent of my eligibility for, VA benefits.

I certify that:

1. I have a total and permanent disability, as defined in Section 1;

2. If I am a veteran applying for TPD discharge based on a qualifying VA disability determination, I have read and understand the information in Section 6; and

3. If I am applying for TPD discharge based on a qualifying SSA disability determination or a certification from an authorized medical professional, I have read and understand the information in Section 7.

Applicant’s or Representative’s Signature		Date		Representative Name (if applicable)

NOTE: You may designate someone to represent you in matters related to your application. If you wish to designate a representative, you must complete the Applicant Representative Designation: Total and Permanent Disability form.

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

If you need help completing the form, contact us: Phone: 1-888-303-7818 (TTY: dial 711, then phone no.) Email: [email protected] Website: www.disabilitydischarge.com

Applicant Name ___________________________________________ Applicant SSN _______________________

SECTION 4: AUTHORIZED MEDICAL PROFESSIONAL CERTIFICATION

The individual who has asked you to complete this section of the form (“applicant”) has applied for discharge of their federal student loans and/or their TEACH Grant service obligation based on total and permanent disability (TPD), as authorized under federal law and the U.S. Department of Education’s regulations.

One means by which a federal student loan borrower or TEACH Grant recipient can show that they are totally and permanently disabled for purposes of TPD discharge is to have an authorized medical professional certify that they are unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that (1) can be expected to result in death; (2) has lasted for a continuous period of at least 60 months; or (3) can be expected to last for a continuous period of at least 60 months. Substantial gainful activity means a level of work performed for pay or profit that involves doing significant physical or mental activities, or a combination of both. Note: This does not mean that the applicant must be unable to work at all. The applicant must be unable to perform a level of work for pay or profit that involves doing significant physical and/or mental activities.

To complete this section of the application, you must be one of the following:

• A doctor of medicine or doctor of osteopathy legally authorized to practice in a state;

• A nurse practitioner licensed by a state;

• A physician assistant licensed by a state; or

• A certified psychologist at the independent practice level who is licensed to practice in the United States.

The terms “state” and “United States” as used above include the 50 United States, the District of Columbia, American Samoa, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau.

Complete Items 1 through 11 below and on page 5. Do not use abbreviations or insurance codes. Print legibly and initial any changes.

Return the form to the applicant or the applicant’s representative, or send it directly to the U.S. Department of Education at the address shown below.

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

If you have questions, contact us: Phone: 1-888-303-7818 (TTY: dial 711, then phone no.) Email: [email protected] Website: www.disabilitydischarge.com

1. Provide the name and date of birth of the applicant:

Name _________________________________________

Date of Birth ___________________________________

2. Does the applicant have a medically determinable physical or mental impairment that prevents the applicant from engaging in any substantial gainful activity (see above)? If the applicant is able to engage in any substantial gainful activity in any field of work, you must answer "No."

Yes - Continue to Item 3.

No - Do not complete this application.

3. Is the applicant's impairment expected to result in death?

Yes - Skip to Item 5.

No - Continue to Item 4.

4. Has the applicant's impairment lasted or is it expected to last for a continuous period of at least 60 months?

Yes - Continue to Item 5.

No - Do not complete this application.

(Section 4 continues on next page.)

5. Provide your diagnosis of the applicant's impairment (do not use insurance codes or abbreviations):

6. Describe the severity of the applicant's impairment, including, if applicable, the phase of the impairment:

Explain in Items 7 through 11 how the condition prevents the applicant from engaging in any substantial gainful activity in any field of work. Attach additional pages if needed. Enter "N/A" if not applicable. You may include additional information you believe is helpful in understanding the applicant's condition, such as medications or procedures used to treat the condition.

7. Limitations on sitting, standing, walking, or lifting:

8. Limitations on activities of daily living:

9. Residual functionality:

10. Social/behavioral limitations (if any):

11. Global Assessment Function Score (for psychiatric conditions):

Authorized Medical Professional’s Certification

I certify that, in my best professional judgment, the applicant identified in Item 1 on page 4 has a medically determinable physical or mental impairment consistent with my responses in Items 2 through 11. I understand that an applicant who is currently able to engage in any substantial gainful activity in any field of work does not have a total and permanent disability as defined on this form. I am a:

doctor of medicine legally authorized to practice in a state

doctor of osteopathy/osteopathic medicine legally authorized to practice in a state

nurse practitioner licensed by a state

physician assistant licensed by a state

certified psychologist at the independent practice level licensed to practice in the United States

State Where Legally Authorized to Practice or Licensed*		Professional License Number (subject to verification; stamp is acceptable)

*If you are licensed to practice in American Samoa, Puerto Rico, the U.S. Virgin Islands, the Northern Mariana Islands, the Marshall Islands, Micronesia, or Palau, attach a copy of your professional license that clearly shows the expiration date.

Signature (a stamp is not acceptable)				Date (mm-dd-yyyy)				Name (First, Middle, Last)
Address (a stamp is acceptable)		Email				Telephone					Fax

SECTION 5: APPLYING FOR DISCHARGE

The information in Section 5 applies to all applicants.

TPD DISCHARGE SERVICER

The U.S. Department of Education (ED) uses a TPD Discharge Servicer to help process TPD discharge applications. Our TPD Discharge Servicer’s address, and contact information are shown below. In this application, the words “we,” “us,” and “our” refer to ED or our TPD Discharge Servicer.

Telling us that you plan to apply

Contact us as soon as you know that you plan to apply for TPD discharge. To give you time to complete your application, we will then instruct your federal student loan holders to stop requiring you to make loan payments for up to 120 days. If we don’t receive your application within 120 days, you will have to resume making loan payments.

Your loan holder is the organization to which you send your loan payments. The holder of your Direct Loan Program loans or your TEACH Grant Agreement to Serve or Repay (TEACH Grant Agreement) is ED. The holder of your FFEL Program loans may be a lender, a guaranty agency, or ED. The holder of your Perkins Loan Program loans may be a school you attended or ED. Your loan holder may use a servicer to handle billing and other loan matters. In this application, the term “holder” means either your loan holder or loan servicer.

Designating someone to represent you

You can designate someone to represent you in matters related to your discharge request. This can be a family member, attorney, law firm or legal aid society, or other individual or organization authorized to act on your behalf in connection with your application. To designate a representative, you must complete the Applicant Representative Designation: Total and Permanent Disability form. Contact us to obtain this form.

Submitting your discharge application

Make sure that all requested information is included. If your application is incomplete, it may be rejected, or the processing of your application may be delayed. Send your completed application and any required documentation to us at the address shown below. After we receive your application, we will send you a notice that will:

• Confirm that we received your application;

• Explain our application review process; and

• Explain that you are not required to make any loan payments while we review your application.

If you do not submit an application within 120 days of notifying us that you intend to do so, you will have to resume making payments on your loans. If you have a FFEL Program loan and the holder of the loan is a lender, the lender may capitalize any unpaid interest that accrued during the period when you were not required to make payments. This means that the unpaid interest will be added to the principal balance of your loan, and interest will then be charged on the increased loan principal amount. If you have a Direct Loan, a FFEL Program loan that is held by ED or by a guaranty agency, or a Federal Perkins Loan, unpaid interest will not be capitalized.

Where to send your completed application

U.S. Department of Education - TPD Servicing
P.O. Box 87130
Lincoln, NE 68501-7130
Fax: 303-696-5250

If you need help completing the application

Phone: 1-888-303-7818
(TTY: dial 711, then phone no.)
Email: [email protected]
Website: www.disabilitydischarge.com

SECTION 6: TPD DISCHARGE BASED ON DOCUMENTATION FROM THE DEPARTMENT OF VETERANS AFFAIRS

The information in Section 6 applies only if you are a veteran applying for TPD discharge based on documentation from the U.S. Department of Veterans Affairs (VA).

required Documentation to qualify

If you are a veteran, you are considered to have a total and permanent disability if the VA has determined that you are unemployable due to a service-connected disability. Generally, you can meet this standard by providing documentation from the VA showing that you have received one of the following two types of VA disability determinations:

1. A determination that you have a service-connected disability (or disabilities) that is 100% disabling; or

2. A determination that you are totally disabled based on an individual unemployability rating.

You do not qualify for discharge based on a VA determination if your disability is not service-connected.

If you are applying for TPD discharge based on VA documentation as described above, you are not required to have a medical professional complete Section 4.

Our review of your discharge application

We will review the documentation from the VA to determine if you are totally and permanently disabled based on a determination by the VA that you are unemployable due to a service-connected disability.

Determination of your eligibility FOR DISCHARGE

If we determine that you are totally and permanently disabled, you will be notified that your loans and/or TEACH Grant service obligation have been discharged. The discharge will be reported to nationwide consumer reporting agencies (credit bureaus), and any loan payments received on or after the effective date of the VA’s determination that you are unemployable due to a service-connected disability will be refunded to the person who made the payments.

If we determine that you are not totally and permanently disabled, you will be notified. The notification will tell you why we denied your application and will explain the following:

• You must repay your loans under the terms of your promissory notes, and your loans will return to the status they were in at the time you applied for a TPD discharge.

• Your loan holder will tell you when you must resume making loan payments.

• If you applied for a discharge of a TEACH Grant service obligation, you must comply with all terms of your TEACH Grant Agreement.

• You may ask us to re-evaluate your discharge application by providing additional documentation from the VA supporting your eligibility for TPD discharge. If you provide this documentation within 12 months of the date of our notification that you are ineligible for discharge, you do not have to submit a new application. After 12 months, you must submit a new application.

• If the documentation from the VA does not indicate that you are unemployable due to a service-connected disability, you may reapply for discharge by submitting a new application with documentation from the SSA or an authorized medical professional’s certification (see Section 7).

Eligibility for future loans or TEACH Grants

After receiving a TPD discharge, you are not eligible to receive future Direct Loans or TEACH Grants unless you:

• Obtain a certification from a physician that you are capable of substantial gainful activity (see below); and

• Sign a statement acknowledging that the new loan or TEACH Grant service obligation cannot be discharged in the future based on any injury or illness present when the new loan or TEACH Grant is made, unless your condition substantially deteriorates so that you are again totally and permanently disabled.

Substantial gainful activity means a level of work performed for pay or profit that involves doing significant physical or mental activities, or a combination of both.

SECTION 7: TPD DISCHARGE BASED ON DOCUMENTATION FROM THE SOCIAL SECURITY ADMINISTRATION OR AN AUTHORIZED MEDICAL PROFESSIONAL’S CERTIFICATION

The information in Section 7 applies ONLY if you are applying for TPD discharge based on documentation from the Social Security Administration (SSA) or a certification from an authorized medical professional in Section 4.

REQUIRED DOCUMENTATION TO QUALIFY

Social Security Administration (SSA) documentation

If you are eligible for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), you are considered to have a total and permanent disability if you provide a copy of your SSA notice of award, SSA Benefits Planning Query (BPQY) or other acceptable documentation (as determined by ED) showing that you meet one of the following requirements:

1. You qualify for SSDI or SSI based on disability, and your next scheduled disability review has been scheduled between 5 to 7 years from the date of your last SSA disability determination;

2. You qualify for SSDI or SSI based on disability and your next continuing disability review has been scheduled at 3 years;

3. You have an established medical onset date for SSDI or SSI of at least 5 years before the date of your application for TPD discharge, or you have been receiving SSDI or SSI based on disability for at least 5 years before the date of your application for TPD discharge;

4. You qualify for SSDI or SSI based on a compassionate allowance; or

5. You are currently receiving SSA retirement benefits, and immediately before you qualified for SSA retirement benefits, you met one of the requirements described in paragraphs 1 through 4 above.

If you want to submit a BPQY but do not have one, contact the SSA office that issued your award and request form SSA-2459. You may also request a BPQY by calling 1-800-772-1213 or by visiting www.ssa.gov. If you submit documentation other than a notice of award or BPQY, we will review the documentation and will accept it only if it provides sufficient information to determine that you meet the requirements above.

If you are applying for TPD discharge based on SSA documentation as described above, you are not required to have a medical professional complete Section 4.

Certification from an authorized medical professional

You are also considered to have a total and permanent disability if you have an authorized medical professional (see below) certify in Section 4 of this application that you are unable to engage in any substantial gainful activity (see below) because of a medically determinable physical or mental impairment that:

1. Can be expected to result in death;

2. Has lasted for a continuous period of at least 60 months; or

3. Can be expected to last for a continuous period of at least 60 months.

An authorized medical professional who may complete Section 4 of this application is:

1. A doctor of medicine or doctor of osteopathy legally authorized to practice in a state;

2. A nurse practitioner licensed by a state;

3. A physician assistant licensed by a state; or

4. A certified psychologist at the independent practice level who is licensed to practice in the United States.

The terms state and United States as used above include the 50 United States, the District of Columbia, American Samoa, the Commonwealth of Puerto Rico, Guam, the U.S. Virgin Islands, the Commonwealth of the Northern Mariana Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau.

Substantial gainful activity means a level of work performed for pay or profit that involves doing significant physical or mental activities, or a combination of both.

Our review of your discharge application

If you submit a discharge application accompanied by an award of benefits notice from the SSA, SSA Benefits Planning Query (BPQY), or other acceptable documentation, we will review that documentation to determine if it meets the requirements described above under Social Security Administration documentation.

If you submit a discharge application supported by an authorized medical professional’s certification in Section 4, we will review the certification and any accompanying documentation to determine if you are totally and permanently disabled as described above under Certification from an authorized medical professional. We may also contact the authorized medical professional for additional information, or may arrange for an additional review of your condition by an independent physician or other medical professional at our expense. Based on the results of this review, we will determine your eligibility for a discharge.

If you are applying for TPD discharge based on a certification from a medical professional, you must submit your application within 90 days of the date of the medical professional’s signature in Section 4.

If we determine during our review of your application that you received a Direct Loan or a TEACH Grant before the date we received the SSA documentation, or before the date the authorized medical professional certified your application in Section 4, and a disbursement of that loan or grant is made after that date, but before we have granted a discharge, we will stop processing your discharge application until you ensure that the full amount of the disbursement is returned to us.

If we determine during our review of your application that a new Direct Loan or a new TEACH Grant was made to you on or after the date we received the SSA documentation, or on or after the date the authorized medical professional certified your application in Section 4, but before we have granted a discharge, we will deny your discharge request. You will have to resume making loan payments and you will again be responsible for complying with the terms of your TEACH Grant Agreement.

Determination of your eligibility FOR DISCHARGE

If we determine that you are totally and permanently disabled, we will notify you that your loans and/or TEACH Grant service obligation have been discharged, and that you will be subject to a post-discharge monitoring period (see below) for three years beginning on the discharge date. The notification of discharge will explain the condition under which we will reinstate your obligation to repay your loan or to complete your TEACH Grant service obligation. The discharge will be reported to nationwide consumer reporting agencies (credit bureaus), and any loan payments received on or after the date we received the SSA documentation or after the date the authorized medical professional certified your discharge application will be refunded to the person who made the payments.

If we determine that you are not totally and permanently disabled, you will be notified. The notification will tell you why we denied your application and will explain the following:

• You must repay your loans to your loan holder under the terms of the promissory note you signed, and your loans will return to the status they were in at the time you applied for TPD discharge.

• Your loan holder will notify you of the date you must resume making payments on your loans.

• If you applied for a discharge of a TEACH Grant service obligation, you must comply with all terms of your TEACH Grant Agreement.

• You may ask us to re-evaluate your discharge application by providing additional information regarding your disabling condition that supports your eligibility for discharge. If you provide this documentation within 12 months of the date of our notification that you are ineligible for discharge, you do not have to submit a new application. After 12 months, you must submit a new application.

• If you request a re-evaluation of your TPD discharge application or submit a new TPD discharge application, as described above, your request must include new information regarding your disabling condition that was not provided to us in connection with your prior application for discharge.

Post-discharge monitoring period

If you receive a TPD discharge based on SSA documentation or a certification from an authorized medical professional, you will have to complete a 3-year post-discharge monitoring period that begins on the date the discharge is granted. During this monitoring period we will check to see if you receive any new Direct Loans or new TEACH Grants.

If you receive a new Direct Loan or a new TEACH Grant at any time during the 3-year post-discharge monitoring period, we will reinstate your obligation to repay your discharged loans and/or to complete your discharged TEACH Grant service obligation.

If your loans are reinstated, we will be your loan holder and you will be responsible for repaying your loans to us in accordance with the terms of your promissory notes. Your loans will be returned to the status they were in at the time you applied for TPD discharge. However, you will not be required to pay interest on your loans for the period from the date of the discharge until the date your repayment obligation was reinstated.

If your TEACH Grant service obligation is reinstated, you will again be required to meet all of the terms of your TEACH Grant Agreement and must complete your service obligation within the portion of your 8-year service obligation period that remained after the date of the TPD discharge. If you do not meet the terms of that agreement and the TEACH Grant funds you received are converted to a Direct Unsubsidized Loan, you must repay that loan in full, and interest will be charged from the dates that the TEACH Grant funds were disbursed (paid out).

If your obligation to repay your loans or to complete your TEACH Grant service obligation is reinstated, we will tell you the reason for the reinstatement and will explain:

• For a reinstated loan, the first payment will be due no earlier than 90 days following the date of the notification of reinstatement; and

• How you may contact us if you have questions about the reinstatement or if you believe your obligation to repay a loan or complete your TEACH Grant service obligation was reinstated based on incorrect information.

Eligibility for future loans or TEACH Grants

If you are granted a TPD discharge based on SSA documentation or a certification from an authorized medical professional, you are not eligible to receive future Direct Loans or future TEACH Grants unless you:

• Obtain a certification from a physician that you are able to engage in substantial gainful activity; and

• Sign a statement acknowledging that the new loan or TEACH Grant service obligation cannot be discharged in the future on the basis of any injury or illness present when the new loan or TEACH Grant is made, unless your condition substantially deteriorates so that you are again totally and permanently disabled.

In addition, if you request a new Direct Loan or a new TEACH Grant during the post-discharge monitoring period, you must resume payment on the previously discharged loan or acknowledge that you are once again subject to the terms of your TEACH Grant Agreement before you can receive the new loan.

SECTION 8: 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 Where to send your completed application in Section 5).

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