Page 1 of 5



## LOAN DISCHARGE APPLICATION **: FALSE CERTIFICATION**  **( ABILITY TO BENEFIT** **) William D. Ford Federal Direct Loan (Direct Loan) Program**  **Federal Family Education Loan (FFEL) Program** OMB No. 1845-0058 DRAFT FORM Exp. Date XX/XX/XXXX **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 Telephone – Primary Telephone – Alternate E-mail (optional) ___ ___ ___ - ___ ___ - ___ ___ ___ ___

____________________________________

____________________________________

____________________________________ (

_______ )

_______ - _____________ (

_______ )

_______ - _____________

____________________________________ 

### SECTION **2 :**  **ABILITY TO BENEFIT INFOMRATION 1.**  Are you applying for this loan discharge as a student or parent borrower? Student – Skip to Item 4. Parent – Continue to Item 2 . **2.** Student Name (Last, First, MI):

_________________________________________ **3.** Student SSN:

___ ___ ___ - ___ ___ - ___ ___ ___ ___ **4.** Did or you (or, for a Parent PLUS borrower, the student) attend a postsecondary school prior to July 1, 2012 ? Yes – Skip to Item 6 . No – Continue to Item 5 . **5.** Did you (or, for a Parent PLUS borrower, the student), prior to July 1, 2012, officially register at a postsecondary school, and are/were you (or, for a Parent PLUS borrower, the student) scheduled to attend a p rogram at that school ? Yes – Continue to Item 6 . No – You are not eligible for this discharge. **6.** Is the postsecondary school you (or, for a Parent PLUS borrower, the student) attended the same institution that you attended when you received the loan you are requesting be discharged ? Yes – Skip to Item 8 . No – Continue to Item 7 . **7.** Provide the following information about the postsecondary school referenced in Item 4 or 5 : **a.** School Name:

______________________________________ **b.** School Address:

______________________________________

______________________________________ **8.** On what date did you (or, for a Parent PLUS borrower, the student) begin attendance at the postsecondary institution in Item 4 or 5 ?

___ ___ - ___ ___ - ___ ___ ___ ___ **9.** School Name:

_________

_______ __ ____________

___________ **10.** School Address (street, city, state, zip code):

______________________ ___________________

_________________________________________ **11.** Dates of attendance at the school:

___ ___ - ___ ___ - ___ ___ ___ ___ to

___ ___ - ___ ___ - ___ ___ ___ ___ **12.** Name of program of study that you (or, for a parent PLUS borrower, the student) were enrolled in at the school:

_______________________________________ __Page 2 of 5 

### SECTION **2 :**  **ABILITY TO BENEFIT INFOMRATION (CONTINUED) 13.**  Did you (or, for a parent PLUS borrower, the student) have a high school diploma or GED at the time of enrollment at the school? Yes – You are not eligible for this discharge. No – Continue to Item 14. **14.** Did you (or, for a parent PLUS borrower, the student) receive a GED before com pleting the program? Yes No **15.** When did you first enroll in a postsecondary school?

___ ___ - ___ ___ - ___ ___ ___ ___ **16.** Before you (or, for a parent PLUS borrower, the student) were admitted to the school, did the school give an entrance examination? Yes – Continue to Items 17 – 20 No – Skip to Item 22 Don’t know – Skip to Item 22 **17.** Give the date of the test if you know it:

___ ___ - ___ ___ - ___ ___ ___ ___ **18.** Give the name of the test if you know it:

___________________________________ ___ ______ **19.** Give the score on the test if you know it:

____________________________ ___ _____________ **20.** Did anything appear improper about the way the test was given or scored? Yes – Continue to Items 21 – 22 No – Skip to Item 22 **21.** Explain in detail what appeared improper:

____________________________________________

______________________________ ______ ________ **22.** Provide the following about anyone who can support your statement: **a.** Name:

___________________________________ **b.** Address:

_________________________________________

_________________________________________ **c.** Phone number: (

_______ )

_______ - _____________ **23.** Did you (or, for a parent PLUS borrower, the student) complete a developmental or remedial program at the school? Yes – Continue to Items 24 – 27 No – Skip to Item 28 Don’t know – Skip to Item 28 **24.** Provide the name of the program:

_________________________________________ **25.** Provide the dates of the program:

___ ___ - ___ ___ - ___ ___ ___ ___ to

___ ___ - ___ ___ - ___ ___ ___ ___ **26.** Provide the courses you took in the program:

____________________________________________

____________________________________________ **27.** Provide the grades you earned in the program:

____________________________________________

____________________________________________ **28.** Did you (or, for a parent PLUS borrower, the student) successfully complete 6 credits or 225 clock hours of coursework that applied toward a program offered by the school before you received a Direct Loan or FFEL Program loan to pay for attendance in this program? Yes No Don’t know **29.** Did the holder of your loan receive any money back (a refund) from the school on your behalf? Yes – Continue to Items 30 – 31 . No – Skip to Item 32 . Don’t know – Skip to Item 32 . **30.** What was the amount of the refund? $

________________________________________ **31.** Explain why the money was refunded:

___________________

______________________ **32.** Did you (or, for a parent PLUS borrower, the student) make any monetary claim with, or receive any payment from, the school or any third party (see definition in Section 6) in connection with enrollment or attendance at the school? Yes – Continue to Items 33 - 35 No – Submit this form. Don’t Know – Submit this form. **33.** What is the name, address, and phone number of the party with whom the claim was made or from whom payment was received? **a.** Name:

___________________________________ **b.** Ad dress:

_________________________________________

_________________________________________ **c.** Phone number: (

_______ )

_______ - _____________ **34.** What are the amount and the status of the claim? **a.** Amount: $

________________________________ **b.** Status:

______________ ____________________ **35.** What was the amount of any payment received? If none, write “none”. $__________________

___ ______________________Page 3 of 5 

### SECTION **3 : BORROWER**  **CERTIFICATIONS ,**  **ASSIGNMENT, AND AUTHORIZATION**   **I certify** that— **1.** I have read and agree to the terms and conditions for loan discharge, as specified in Section 7. **2.** Under the 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.  **I hereby assign and transfer** to the Department and right to a refund on the amount discharge that I may have from the school identified in Section 2 of this form and/or any owners, affiliates, or assignees of the school, and from any third party that may pay claims for a refund because of the actions of the school, up to the amount discharged by the Department on my loan(s) **.**  **I authorize** the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my req uest or my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future number that I provide for my cellular telephone or other wireless device using automated telephone dialing equipment or artificial or prerecorded voice or text messages. **Borrower 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 Fam ily 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 loan(s) is the U.S. Department of Education (the Department) . The holder of your FFEL Program loan(s) may be a lender, a guaranty agency, or the Department.  **Loan discharge** due to false certification of ability to benefit cancels your obligation (and any endorser’s obligation, if applicable) to repay the remaining portion on a Direct Loan or FFEL Program loan, and qualifies you for reimbursement of any amounts paid voluntarily or though forced collection on the loan. For consolidation loans, only the loan amounts associated with the program of study listed in Section 2 will be considered for discharge . The loan holder reports the discharge to all credit reporting agencies to which the holder previously reported the status of the loan.  The **student** (as in, “or, for pare nt PLUS borrowers, the student”) refers to the student for whom a parent borrower obtained a Federal PLUS Loan or Direct 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 or a holder of a performance bond. 

### SECTION **6 :**  **TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION**  I will provide, upon request, testimony, a sworn statement, or other documentation reasonably available to me that demonstrates to the satisfactory of the U.S. Department of Education (the Department) or its designee that I meet the qualifications for loan discharge based on false certification, or that supports any representation that I made on this form or any accompanying documents.  I agree to cooperate with the Department or the Department’s designee in any enforcement action related to this application .  I understand that this request may be denied, or my discharge may be revoked, if I fail to provide testimony, a sworn statement, or documentation upon request, or if I provide testimony, a sworn statement, or documentation that does not support the material representation that I have made on this form or on any accompanying documents.  I further understand that if my loan is discharged based on any false, fictitious, or fraudulent statements that I knowingly made on this form or on any accompanying documents, I may be subject to civil and criminal penalties under applicable federal law.Page 4 of 5 

### SECTION **4 : INSTRUCTIONS FOR COMPLETING THE FORM**  When completing this form, type or print using dark ink . Enter dates as month -day-year (mm -dd -yyyy) . Use only numbers . Example: February 10, 2014 = 02 -10-2014 . If you need more space to answer any of the items, continue on separate sheets of paper and attach them to this form . Indicate the number of the Item(s) you are answering and include your name and social security number (SSN) on all attached pages. **Return the completed form and any attachments to the address shown in Section**  **7 .**  

### SECTION **7 : WHERE TO SEND THE COMPLETED REQUEST**  Return the completed form and any required documentation to: (If no address is shown, return to your loan servicer.) If you need help completing this form, call: (If no telephone number is shown, call your loan servicer.)


### SECTION **8 : 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 Federal Family Education Loan (FFEL) Program or 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 co llecting 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 FFEL and/or Direct Loan P rograms, 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) becomes delinquent or defaults . 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 fin ancial 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 m ade 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 cancell ations, 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 m ay 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 eve nt 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 m ay 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 . DisclosuresPage 5 of 5 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 1845-0058 . 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 collection of information . 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 o r concerns regarding the status of your individual submission of this form, **contact your loan holder(s) (see Section**  **7 ) directly.**