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oan Rehabilitation: Income and

Deleted: L

OMB No.1845-0120
Form Under Review

Expense Information

Formatted: Tab stops: 6.06", Centered + Not at 6.5"
Deleted: Approved
Deleted: 6/30/2026

Exp. Date: TBD

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

Formatted: Tab stops: 5.44", Left + Not at 5.94"

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 Information
Please enter or correct the following information.
Check this box if any of your information has changed.
Social Security Number (SSN):
Name:
Address:
City:

State:

Zip Code:

Telephone - Primary:
Telephone - Alternate:
Email (Optional):

Section 2: Household Income and Reasonable and Necessary Monthly Expenses
You received this form because you asked to rehabilitate your defaulted loans, but objected to the
payment amount your loan holder calculated using the 15% formula (see Section 6). After receiving
this form, your loan holder will offer an alternative payment amount. The alternative amount may be
less or more than the amount calculated using the 15% formula. To begin rehabilitating your defaulted
loans, you must choose between the two amounts. To rehabilitate, you must make 9 on time
payments of that amount over a period of 10 consecutive months.
Provide the monthly income and expense information listed below. Include documentation of these
sources of income or expenses if your loan holder asks you to. Include your spouse's income only if
your spouse contributes to your household income. Your loan holder has the authority to determine if

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Deleted: ontime

Borrower Name:

Borrower SSN:

the claimed amount of any expense is reasonable and necessary. Before entering your monthly
income and expenses, carefully read the entire form, including Sections 5, 6, and 7.

10

MONTHLY INCOME

8.

Total monthly income
(sum of items 1 through 7)

1.

Your employment
income

2.

Spouse’s
employment
income

3.

Child support received

4.

Social Security benefits

11. Housing

5.

Worker’s compensation

12. Utilities

6.

Public assistance

13. Basic communication

List types

9.

If your total monthly income is $0, explain
your means of support MONTHLY
EXPENSES

10. Food

14. Necessary medical/dental

15. Necessary insurance
7.

Other income

Describe

16. Transportation

Number of vehicles

17. Child/dependent care

Borrower Name:

18. Required
child/spousal
support

Borrower SSN:

Describe

19. Federal
student loan
payments
20. Private student loan payments

22. Total monthly expenses (sum of items 10
through 21)

21. Other expenses
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Continue to Sections 3 and 4 on page 3.

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Section 3: Family Size and Spouse Identification
Your family size includes you, your spouse, and your children (including unborn children who will be
born before the end of the current calendar year), if the children will receive more than half of their
support from you. Your family size includes other people only if they live with you now, receive more
than half of their support from you now, and will continue to receive this support from you for the year
for which you are certifying your family size. Support includes money, gifts, loans, housing, food,
clothes, car, medical and dental care, and payment of college costs.
23. Family Size
24. Are you requesting rehabilitation of a Direct Consolidation Loan or a Federal Consolidation Loan
that was made jointly to you and your spouse?
Yes. Enter your spouse’s name and SSN:
Spouse’s Name:
Spouse’s SSN:
No. Continue to Section 4.

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Borrower Name:

Borrower SSN:

Section 4: Understandings, Certifications, and Authorization
I understand that:
1.

I have received this form because I requested the opportunity to rehabilitate my defaulted
loans and objected to the reasonable and affordable monthly payment amount calculated
using the 15% formula.

2.

My loan holder will calculate an alternative reasonable and affordable monthly payment
amount that will be based solely on the information I provide on this form and, if requested,
supporting documentation.

3.

If I do not accept either the 15% formula payment amount or the payment amount
determined by my loan holder based on information from this form, the loan rehabilitation
process will not proceed and I will be required to repay my defaulted loans in accordance
with the terms of the loan and applicable law.

4.

If I do not provide any supporting documentation requested by my loan holder by the
deadline specified by my loan holder, my request for loan rehabilitation will not be
considered.

5.

If I want to rehabilitate a defaulted Direct Consolidation Loan or Federal Consolidation Loan
that was made jointly to me and my spouse and am requesting an alternative payment
amount, my spouse and I must each sign below.

Borrower Name:

Borrower SSN:

6.

If I
rehabilitate a loan and default on the same loan again in the future, I may not rehabilitate
that loan a second time.

7.

I must notify my loan holder immediately if my address changes.

8.

If my loan is rehabilitated, my loan will be sold or transferred to a new loan holder or loan
servicer. After the sale or transfer, I will be asked to select a repayment plan. If I do not
select a repayment plan, and all of my loans were disbursed prior to July 1, 2026, then my
loans will be placed on the standard repayment plan. If I do not select a repayment plan,
and any of my loans were disbursed on or after July 1, 2026, then my loans will be placed
on the Tiered Standard Plan. Both the Standard Repayment Plan and Tiered Standard Plan
will likely require me to make a much higher monthly payment amount than the payment I
made to rehabilitate my loan.

9.

After my loan is rehabilitated, I may be eligible to repay my loans under an income-driven
repayment plan that bases my payment on my income and family size or number of
dependents depending on the income-driven repayment plan I qualify for.

10. I can learn more about the eligibility requirements and application process for income-driven
repayment plans by visiting StudentAid.gov/IDR or by asking my loan holder.
I certify that (1) the information that I have provided on this form is true and correct and (2) upon
request, I will provide additional documentation to my loan holder to support the information I have
provided in this form.
I authorize the loan holder to which I submit this request (and its agents or contractors) to contact me
regarding my request or my loans, including the repayment of my loans, at any number that I provide
on this form or any future number that I provide for my cellular telephone or other wireless device
using automated dialing equipment or artificial or prerecorded voice or text messages.

Borrower’s Signature:

Date (mm/dd/yyyy):

Spouse’s Signature:

Date (mm/dd/yyyy):

Your spouse must sign this form only if you entered your spouse's name and SSN in Section 3.
Please omit pages 5–10 when mailing or faxing back.

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Deleted: s, which

Deleted: An income-driven repayment plan is the
type of repayment plan most likely to have a
monthly payment similar to the payment I made to
rehabilitate my loans.…

Section 5: Instructions
If you are not completing this form electronically, type or print using dark ink. Enter dates as
month/day/year (mm/dd/yyyy). Use only numbers. Example: March 14, 2027 = 03/14/2027. Include
your name and the account numbers for your defaulted loans on any documentation that you are
required to submit with this form. If you need help completing this form, contact your loan holder.
Return the completed form to the address shown in Section 8
MONTHLY INCOME IN SECTION 2 (ITEMS 1-9)
Your loan holder may request supporting documentation for any income items.
Employment income documentation may include a pay stub or a letter from the employer stating the
income paid to you by that employer.
Child support, Social Security benefits, worker’s compensation, or public assistance
documentation may include copies of benefits checks or a benefits statement, a letter from a court,
a governmental body, or the individual paying child support, specifying the amount of the benefit.
Public assistance: Identify the type of public assistance received (see definition of “public
assistance” in Section 6).
Other income: Include any other income not covered in items 1-6 and identify the source of the
income.

If you report that your Total Monthly Income is zero, explain your means of support in Item 9.
MONTHLY EXPENSES IN SECTION 2 (ITEMS 10-22)
For each monthly expense, provide the amount you usually spend each month. Your loan holder may
request supporting documentation for any of these items. Do not include a single expense in more
than one category. If you have no expenses under a category, enter 0 for that category.
Food: Include the amount spent on food, even if purchased using the Supplemental Nutrition
Assistance Program (SNAP) (food stamps).
Housing: Include the amount spent on housing and shelter, such as rent, required security deposits,
mortgage payments (including principal, interest, taxes, and homeowner’s insurance), maintenance,
and repairs.
Utilities: Include the amount spent on housing-related utility bills, such as gas, electric, fuel oil, water,
sewer, trash, and recycling.

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Deleted: 2017

Basic communication: Include the amount spent on basic communication expenses, such as basic
telephone, internet, and cable TV.
Medical and dental: Include the amount spent on necessary medical and dental expenses and
procedures not covered by insurance, such as medically necessary prescriptions and nonprescription
medications, and medically necessary nutritional supplements. Do not include any costs relating to
medical or dental insurance premium payments.
Insurance: Include the amount spent on insurance, such as necessary renter’s, auto, medical,
dental, or life insurance. Include any amounts paid toward insurance premiums. However, if the
income amount you listed under Monthly Income already reflects deductions from your pay for
insurance premiums, do not list the amount of these deductions as an Insurance expense. Include
homeowner’s insurance under Item 11 (Housing).
Transportation: Include the amount spent on basic transportation expenses such as fuel, car
payments, basic vehicle maintenance, public transportation, tolls, and parking. Also list the number of
vehicles for which you are claiming related transportation expenses.
Child/dependent care: Include the amount spent on care for children or other dependents in the
household and other work-related child/dependent care expenses.
Legally required child /spousal support: Include the amount spent on legally required child support
and spousal support.
Federal student loan payments: Include the total monthly amount you pay on any federal student
loans except for the defaulted loans you are trying to rehabilitate, unless you are subject to
mandatory withholding such as wage garnishment or Treasury offset (e.g., your Social Security is
being garnished). If you are subject to wage garnishment or Treasury offset include the amount that is
collected from you each month.
Private student loan payments: Include the total monthly amount you pay on any private student
loans. Include any type of payment, voluntary or otherwise.
Other expenses: Include the amount spent on any other necessary expenses not covered in items
10 - 20 and explain these expenses. These other expenses will be considered only if the Department
of Education determines that they should be considered. If more space is needed to list other
expenses, attach a separate piece of paper and include your name and Social Security Number at
the top.

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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 PLUS Loans, Federal Consolidation Loans, and Federal
Supplemental Loans for Students (SLS).
Rehabilitation of your defaulted loan occurs only after you have made 9 voluntary, reasonable and
affordable monthly payments within 20 days of the due date during 10 consecutive months and, for
FFEL loans held by a guaranty agency, when the loan has been sold to an eligible lender or assigned
to the U.S. Department of Education (the Department). When you rehabilitate your loans, you will
regain all the benefits of the Direct Loan Program or FFEL Program, including eligibility for
deferments or forbearances and for a repayment plan with a monthly payment amount based on your
income. You will also regain eligibility to receive additional federal student aid, including additional
federal student loans. After a defaulted loan is rehabilitated, your loan holder will instruct any
consumer reporting agency (credit bureau) to which the default was reported to remove the default
from your credit history.
Reasonable and affordable payment amount means a monthly payment determined by the loan
holder based either on the 15% formula or on information provided in this form and supporting
documentation. It cannot be a percentage of your total loan balance or based on information
unrelated to your total financial circumstances.
The 15% formula means 15% of the amount by which your Adjusted Gross Income exceeds 150% of
the poverty guideline amount that is applicable to your family size and state, divided by 12. Your
minimum payment may not be less than $5.00.

The loan holder of a defaulted Direct Loan Program loan is the Department. The loan holder of a
defaulted FFEL Program loan may be a guaranty agency or the Department.
Public assistance means payments you receive under a federal or state program. These assistance
programs include, but are not limited to, Temporary Assistance for Needy Families (TANF),
Supplemental Security Income (SSI), Food Stamps/Supplemental Nutritional Assistance Program
(SNAP), or state general public assistance.

Section 7: Loan Rehabilitation Agreement
To rehabilitate your loan, you must accept either the monthly rehabilitation payment amount
determined using the 15% formula, or the payment amount determined based on the monthly
income, monthly expenses, and family size information that you provide on this form and on any
requested supporting documentation.
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Your loan holder will provide you with a written loan rehabilitation agreement confirming your monthly
rehabilitation payment amount.
To accept the loan rehabilitation agreement, you must sign the agreement and return it to your loan
holder.
During the loan rehabilitation period, the loan holder will limit contact with you on the loan being
rehabilitated to collection activities that are required by law or regulation, and to communication that
supports the rehabilitation.
If you do not accept either monthly payment amount, your rehabilitation request will not be considered
any further.

Section 8: Where to Send the Completed Form
Return the completed form and any documentation to: (If no address is shown, return to your loan
holder.)

Section 9: Help with Completing the Form
If you need help completing this form, call: (If no telephone number is shown, call your loan holder.)

Section 10: 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 William D. Ford Federal Direct Loan (Direct Loan) Program or the Federal Family
Education Loan (FFEL) Program and giving us your SSN are voluntary, but you must provide the
requested information, including your SSN, to participate.

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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 Direct Loan and/or FFEL 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

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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 such collection displays a valid OMB control
number. The valid OMB control number for this information collection is 1845-0120. Public reporting
burden for this collection of information is estimated to average 60 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 682.405 or 685.211. If you have
questions regarding the status of your individual submission of this form, contact your loan holder
(see Section 9).

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