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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 program 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:

_________________________________________
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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 completing 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. Address: 

_________________________________________

_________________________________________

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”.

$___________________________________________
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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 

request 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 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 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 parent 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.
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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 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 FFEL and/or Direct Loan Programs, 

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 caseby-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 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 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 
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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 or 

concerns regarding the status of your individual 

submission of this form, contact your loan holder(s) (see 

Section 7) directly.