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<tr class="odd">
<td colspan="2"><img src="media/image1.bmp" /></td>
<td colspan="10"><h1 id="income-contingent-repayment-plan">Income
Contingent Repayment Plan</h1>
<p><strong>Alternative Documentation of Income</strong></p>
<p>William D. Ford Federal Direct Loan Program</p>
<p>Federal Direct Stafford/Ford Loans, Federal Direct Unsubsidized
Stafford/Ford Loans,</p>
<p>Federal Direct Subsidized Consolidation Loans, Federal Direct
Unsubsidized Consolidation Loans</p>
<p><strong>WARNING:</strong> Any person who knowingly makes a false
statement or misrepresentation on this form shall be subject to
penalties which may include fines, imprisonment, or both, under the U.S.
Criminal Code and 20 U.S.C. 1097.</p></td>
</tr>
<tr class="even">
<td colspan="12"><em><strong>Instructions</strong></em></td>
</tr>
<tr class="odd">
<td colspan="12"><p><strong>YOU ARE REQUIRED</strong> to complete this
form if you are repaying your Direct Loans under the Income Contingent
Repayment (ICR) Plan and:</p>
<ul>
<li><p>You are in your first year of repayment on a Direct
Loan;</p></li>
</ul>
<ul>
<li><p>You are in your second year of repayment on a Direct Loan and
have been notified that alternative documentation of your income is
required; or</p></li>
</ul>
<ul>
<li><p>You have been notified that the Internal Revenue Service (IRS) is
unable to provide the U.S. Department of Education (the Department) with
your Adjusted Gross Income (AGI) or that of your spouse (if you are
married).</p></li>
</ul>
<p><strong>YOU MAY</strong> complete this form if:</p>
<ul>
<li><p>You are repaying your Direct Loans under the ICR Plan and your
AGI, as reported on your most recently filed federal tax return, or that
of your spouse (if you are married) does not reasonably reflect your
current income.</p></li>
<li><p>Your AGI and your spouse’s AGI (if you are married) does not
reflect your current income and ability to repay your loan(s) in
circumstances such as loss or change of employment by you or your spouse
(if you are married).</p></li>
</ul>
<p>In cases where alternative documentation of your income is used, the
amount of your monthly payment under the ICR Plan is based on the
current income information you and your spouse (if you are married)
provide and is reevaluated annually. To submit alternative documentation
of your income, you must attach the required documentation, complete and
sign this form, and return it to the address on the back of this form.
If you are married, your spouse also must complete and sign the
applicable sections of this form and submit the required documentation.
If you need assistance, please call</p>
<p>1-800-848-0979, or TDD 1-800-848-0983.</p></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><em><strong>Section 1: Identifying Information (Must be
completed by the borrower and the borrower’s spouse, if
married.)</strong></em></td>
</tr>
<tr class="even">
<td colspan="6">Borrower's Name (please print clearly):</td>
<td></td>
<td colspan="5">Your Spouse’s Name (please print clearly):</td>
</tr>
<tr class="odd">
<td colspan="6"><h5 id="last-name-first-name-middle-initial">Last Name
First Name Middle Initial</h5></td>
<td></td>
<td colspan="5">Last Name First Name Middle Initial</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="6"><p>Borrower’s Social Security Number:</p>
<p>|__|__|__|-|__|__|-|__|__|__|__|</p></td>
<td></td>
<td colspan="5"><p>Your Spouse’s Social Security Number:</p>
<p>|__|__|__|-|__|__|-|__|__|__|__|</p></td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><em><strong>Section 2: Income Information (Must be
completed by the borrower and the borrower’s spouse, if
married.)</strong></em></td>
</tr>
<tr class="even">
<td colspan="12"><strong>You must</strong> list all taxable income you
are currently receiving (i.e., income from employment, unemployment
income, dividend income, interest income, tips, alimony). Include the
amount of money received, how often you receive this money, and your
employer (if any) or the source of your income if you are not employed.
If you are married, your spouse’s income and documentation of this
income also must be provided. <strong>All income</strong> reported under
this section must have supporting documentation (i.e., pay stubs,
letters from your employer containing your income, interest or bank
statements, dividend statements, canceled checks, or, when these forms
of documentation are unavailable, a signed statement explaining your
income source(s) and giving the addresses of these sources) submitted
with this application. <em><strong>All supporting documentation must not
be more than 90 days old</strong></em>. If you have more than two
sources of income, provide the information requested in this section on
a separate piece of paper and mail it with this form. Do not report
untaxed income such as Supplemental Security Income, child support, or
Temporary Assistance to Needy Families (TANF). If your income or the
income of your spouse changes significantly after your submission of
this form, you must notify the Direct Loan Servicing Center of this
change.</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Borrower’s Income:</strong></td>
</tr>
<tr class="even">
<td rowspan="2">Amount of Income</td>
<td colspan="10">Frequency of Payment (Please check the appropriate
box.)</td>
<td rowspan="2">Employer or Source of Income</td>
</tr>
<tr class="odd">
<td colspan="2">Weekly</td>
<td>Bi-weekly</td>
<td>Semi-monthly</td>
<td colspan="3">Monthly</td>
<td colspan="3">Yearly</td>
</tr>
<tr class="even">
<td>$</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td>$</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="12"> Check this box if you do not have any taxable income
and receive only untaxed income such as Supplemental Security Income,
child support, or TANF.</td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="12"><strong>Spouse’s Income:</strong></td>
</tr>
<tr class="odd">
<td rowspan="2">Amount of Income</td>
<td colspan="10">Frequency of Payment (Please check the appropriate
box.)</td>
<td rowspan="2">Employer or Source of Income</td>
</tr>
<tr class="even">
<td colspan="2">Weekly</td>
<td>Bi-weekly</td>
<td>Semi-monthly</td>
<td colspan="3">Monthly</td>
<td colspan="3">Yearly</td>
</tr>
<tr class="odd">
<td>$</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td>$</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12"> Check this box if you do not have any taxable income
and receive only untaxed income such as Supplemental Security Income,
child support, or TANF.</td>
</tr>
<tr class="even">
<td colspan="12"></td>
</tr>
<tr class="odd">
<td colspan="12"><em><strong>Section 3: Certification and Signature
(Must be completed by the borrower and the borrower’s spouse, if
married.)</strong></em></td>
</tr>
<tr class="even">
<td colspan="12"><strong>Certification:</strong> I certify that all of
the information reported to qualify for alternative documentation of
income is true and complete to the best of my knowledge. I agree to
provide to the U.S. Department of Education on an annual basis (or as
required by the Department) alternative documentation of my income for
the purpose of determining my appropriate repayment amount under the ICR
Plan. I understand that if I do not provide this information the
Department will base my ICR amount on my AGI, as reported by the IRS,
or, in some instances, I will not be allowed to repay my loan(s) under
the ICR Plan. I understand that the Department may be requesting my
income information from the IRS even if alternative documentation of my
income is accepted. I understand that if I am married my spouse’s income
information, documentation, and signature are required.</td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="9"><h3 id="borrowers-signature">Borrower’s
Signature</h3></td>
<td></td>
<td colspan="2"><h4 id="date-form-was-signed">Date form was
signed</h4></td>
</tr>
<tr class="odd">
<td colspan="9"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="9"><h3 id="spouses-signature">Spouse’s Signature</h3></td>
<td></td>
<td colspan="2"><h4 id="date-form-was-signed-1">Date form was
signed</h4></td>
</tr>
</tbody>
</table>

+-----------------------------------------------------------------------+
| ***Important Notices***                                               |
+-----------------------------------------------------------------------+
|                                                                       |
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| **Return this form to:**                                              |
|                                                                       |
| **U.S. Department of Education**                                      |
|                                                                       |
| ###### Direct Loan Servicing Center                                   |
|                                                                       |
| **P.O. Box 5800**                                                     |
|                                                                       |
| **Greenville, TX 75403-5800**                                         |
|                                                                       |
| If you need assistance in completing this form, call 1-800-848-0979.  |
| Individuals who use a telecommunications device for the deaf (TDD)    |
| may call 1-800-848-0983.                                              |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| ##### PRIVACY ACT NOTICE                                              |
|                                                                       |
| The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following   |
| notice be provided to you:                                            |
|                                                                       |
| The authority for collecting the requested information from and about |
| you is §451 [et seq.]{.underline} of the Higher Education Act (HEA)   |
| of 1965, as amended (20 U.S.C. 1087a [et seq.]{.underline}) and the   |
| authorities for collecting and using your Social Security Number      |
| (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C.  |
| 7701(b). Participating in the William D. Ford Federal Direct Loan     |
| (Direct Loan) Program and giving us your SSN are voluntary, but you   |
| must provide the requested information, including your SSN, to        |
| participate.                                                          |
|                                                                       |
| The principal purposes for collecting the information on this form,   |
| including your SSN, are to verify your identity, to determine your    |
| eligibility to receive a loan or a benefit on a loan (such as a       |
| deferment, forbearance, discharge, or forgiveness) under the Direct   |
| Loan Program, to permit the servicing of your loan(s), and, if it     |
| becomes necessary, to locate you and to collect and report on your    |
| loan(s) if your loan(s) become delinquent or in 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 loan(s), to enforce the terms of the loan(s), 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 efficiently to       |
| submit student enrollment status, disclosures may be made to guaranty |
| agencies or to financial and educational institutions. To counsel you |
| in repayment efforts, disclosures may be made to guaranty agencies,   |
| to financial and educational institutions, or to federal, state, or   |
| local agencies.                                                       |
|                                                                       |
| In the event of litigation, we may send records to the Department of  |
| Justice, a court, adjudicative body, counsel, party, or witness if    |
| the disclosure is relevant and necessary to the litigation. If this   |
| information, either alone or with other information, indicates a      |
| potential violation of law, we may send it to the appropriate         |
| authority for action. We may send information to members of Congress  |
| if you ask them to help you with federal student aid questions. In    |
| circumstances involving employment complaints, grievances, or         |
| disciplinary actions, we may disclose relevant records to adjudicate  |
| or investigate the issues. If provided for by a collective bargaining |
| agreement, we may disclose records to a labor organization recognized |
| under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors |
| for the purpose of performing any programmatic function that requires |
| disclosure of records. Before making any such disclosure, we will     |
| require the contractor to maintain Privacy Act safeguards.            |
| Disclosures may also be made to qualified researchers under Privacy   |
| Act safeguards.                                                       |
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|                                                                       |
+-----------------------------------------------------------------------+
| **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 currently valid OMB control number.  |
| The valid OMB control number for this information collection is       |
| 1845-0016. The time required to complete this information collection  |
| is estimated to average 0.33 hours (20 minutes) per response,         |
| including the time to review instructions, search existing data       |
| resources, gather and maintain the data needed, and complete and      |
| review the information collection. **If you have comments concerning  |
| the accuracy of the time estimate(s) or suggestions for improving     |
| this form, please write to:** U.S. Department of Education,           |
| Washington, DC 20202-4651. ***Do not send the completed form to this  |
| address.***                                                           |
|                                                                       |
| **If you have any comments or concerns regarding the status of *your  |
| individual submission* of this form, write directly to:**             |
|                                                                       |
| **U.S. Department of Education**                                      |
|                                                                       |
| ###### Direct Loan Servicing Center                                   |
|                                                                       |
| **P.O. Box 5800**                                                     |
|                                                                       |
| **Greenville, TX 75403-5800**                                         |
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