Loan Discharge Applications (DL/FFEL/Perkins)

83C-1845-0058_FC HSGS_ExpDate 2026-12-31 (1)

Loan Discharge Applications (DL/FFEL/Perkins)

OMB: 1845-0058

Document [docx]

Download: docx | pdf

LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION
(HIGH SCHOOL GRADUATION STATUS)

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

OMB No. 1845-0058
Form Approved
Exp. Date 12/31/2026

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

Carefully read the entire application before completing it. In Sections 2 and 3, complete each item unless the item is identified as optional or the instructions tell you to skip an item.

SECTION 2: DISCHARGE ELIGIBILITY INFORMATION

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.

Student Name (Last, First, MI):

______________________________________________

Student SSN: ___________________________________
Enter the earliest date you (or the student) attended or officially registered for classes at a postsecondary school:

______________________________________________

OR Don't Know

Provide the name and address of the school referenced in Item 4:

School Name: ___________________________________

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

Is the postsecondary school in Item 5 the same school you (or the student) attended when you received the loans you want discharged?

Yes - Skip to Item 11.

No - Continue to Item 7 and enter the name and address of the school you (or the student) attended when you received the loans you want discharged.

School Name: ___________________________________

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

Dates that you (or the student) attended the school:

First Date: ______________

OR

Don’t Know

Last Date: ______________

Don’t Know
Name the program you (or the student) were enrolled in when you received the loans you want discharged:

______________________________________________

Did you (or the student) complete the program of study identified in Item 9?

Yes.

Borrower Name ____________________________________________________ Borrower SSN _____________________________

SECTION 2: DISCHARGE ELIGIBILITY INFORMATION (CONTINUED)

Borrower Name ____________________________________________________ Borrower SSN _____________________________

SECTION 2: DISCHARGE ELIGIBILITY INFORMATION (CONTINUED)

List the courses you (or the student) took:
Provide the grades you (or the student) earned:

SECTION 3: REFUNDS OR PAYMENTS

Did the school refund any money to you or any third-party?

Yes - Continue to Items 28-29.

No - Skip to Item 30.

Don't Know - Skip to Item 30.

What was the amount of the refund? ________________
Explain why the money was refunded and to whom:
Have you (or the student) requested or received a refund or payment from the school or any third party (see Section 5) for any loan that you are requesting be discharged?

Yes - Continue to Items 31-33.

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.

Provide the name, address, and telephone number of the organization you (or the student) requested or received a payment from:

Name: _______________________________________

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

Telephone Number: ______________________________

What is the amount and the status of the request?

Amount: _______________________________________

Status: ________________________________________

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

______________________________________________

SECTION 4: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION

I certify that:

I have read and agree to the terms and conditions for loan discharge, as specified in Section 6.
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.

Borrower's Signature ___________________________________________________ Date _______________________________

SECTION 5: 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 application mean either your loan holder or your servicer.

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 6: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION (HIGH SCHOOL GRADUATION STATUS)

You are eligible to have your loans discharged based on false certification (high school graduation status) if:

The school certified your eligibility to receive a loan even though you: (1) reported that you did not have a high school diploma or its equivalent and (2) did not satisfy the alternative to graduation from high school requirements that were in effect when your loan was originated (for a Direct Loan) or when the school certified the loan application (for a FFEL loan) or
You reported that you did not have a high school diploma or its equivalent, and the school certified your eligibility to receive a loan based on: (1) a high school graduation status falsified by the school, or (2) a high school diploma falsified by the school or a third party to which the school referred you.

For purposes of false certification (high school graduation status) loan discharge, a loan made under the Direct Loan Program is originated when the school submits the loan record to the U.S. Department of Education, and a loan made under the FFEL program was certified when the school transmitted the certification of the borrower’s eligibility for the loan to the lender.

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 7: 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 2 and 3 and on any attached pages. Return the completed application and documentation to the address shown in Section 8.

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 Statement

Authority: 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).

Purpose: The principal purposes for collecting the information on the Loan Discharge Application: False Certification (High School Graduation Status) 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 William D. Ford Federal Direct Loan (Direct Loan) and/or Federal Family Education Loan (FFEL) 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 Loan Discharge Application: False Certification (High School Graduation Status) 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 Loan Discharge Application: False Certification (High School Graduation Status) 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

SECTION 9: IMPORTANT NOTICES (CONTINUED)

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 or the FFEL Program is voluntary, but providing the Department your SSN and 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 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.

Page 1 of 6

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Jon Utz
File Modified	0000-00-00
File Created	2024-07-23

First Date: ______________	OR	Don’t Know
Last Date: ______________	OR	Don’t Know