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## LOAN DISCHARGE APPLICATION **: UNPAID REFUND**  **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 m ay 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) ___ ___ ___ - ___ ___ - ___ ___ ___ ___

____________________________________

____________________________________

____________________________________ ( __ _____ ) _______ -
_____________ ( _______ ) _______ -
_____________

______________________ ______________ 

### SEC**TION 2**  **: REFUND INFORMATION**  **Before responding, carefully read the entire form, including Section 5, 6, and 7 o f**  **this form.** If you (or, for parent PLUS borrowers, the student) are currently attending the school, you are not eligible for this type of discharge. You should contact the school about the refund that you believe you are owed. **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.** School Name :

_________

_______ __ ____________

___________ **5.** School Address (street, city, state, zip code):

_________________________________________

______________

___________

____ ____________ **6.** Is this school still open? Yes – F irst contact the school to attempt to resolve the issue. Skip to Item 8 . No – Continue to Item 7 . **7.** If this school is closed, were you (or, for parent PLUS borrowers, was the student) attending the school when it closed? Yes – You may be eligible for a closed school discharge. If you are unsure about which type of loan discharge is most appropriate fo r you, contact your loan holder. Continue to Item 8 . No – Continue to Item 8 . **8.** Do you have any other pending or approved application(s) for discharge of a lo an you obtained to attend this school? Yes – Complete Items 10 – 12 . No – Continue to Item 9 . **9.** Has this school or any third party (see Section 6) made or is the school/third party considering you for a refund or payment for any loan for which you are requesting a discharge? Yes – Complete Items 10 – 12 . No – Skip to Section 3 if response to Item 8 was “No”. For items 10 – 12, attach additional pages if you need to report additional discharge s, refund s, or payments . **10.** Reason for discharge, refund, or payment:

_________________________________________

_________________________________________

____ ______ _____ __________________________ **11.** From whom did you request or from whom did you receive the discharge, refund , or payment? **a.** Name : _______________

_________________ **b.** Phone Number : ( _______ ) _______ -
_____________ **12.** Amount you receive d or that you expect to receive: $

___________

______________

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### SECTION 3: **REFUND INFORMATION (CONTINUED)**  **If you are unable to provide any of the requested information, write “Don’t Know”. Attach a copy of any**  **documentation that supports your responses to Items 15**  **through 19**  . Examples of documentation may include, but are not limited to, the school’s catalog, refund policy, tuition bill(s), enrollment contract, student account statement, registration forms, withdrawal forms, attendance records, and any correspondence from the school that contains information about the refund you believe the school owes you. **13.** Do you have documentation from the school showing the amount of the unpaid refund? Yes - Attach the documentation and continue to Items 14 . No – Skip to Item 15 . **14.** Do you believe that the amount of the refund shown in the documentation is correct? Yes - Skip to Section 4. No – Continue to Item 15 . **15.** What a mount do you believe the school owes you? $___________________

________________ **16.** Why do you believe the school owes you this amount?

_________________________________________

_________________________________________

_________

__________________________ ______ **17.** You (or, for parent PLUS borrowers, the student’s)

first and last date of attendance at the school :

___ ___ - ___ ___ - ___ ___ ___ ___ to

___ ___ - ___ ___ - ___ ___ ___ ___ OR Never Attended **18.** You (or, for parent PLUS borrowers, the student’s) program of study at the school:

_________________________________________

_____________________________________ ____ **19.** If your (or, fo r parent PLUS borrowers, the student’s) last date of enrollment was **on or after October 7, 2000** , enter the total amount of the federal grants and loans received for any part of the period of enrollment for which the loan was intended. $

_

___________________

____________ **Note** : If your (or, for parent PLUS borrowers, the student’s) last date of enrollment was before October 7, 2000, please contact your servicer for information about the documentation you must provide to request a discharge of your loan. 

### S **ECTION 4**  **: BORROWER**  **ASSIGNMENT, CERTIFICATION**  **S ,**  **AND AUTHORIZATION**  **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 certif** 

**y** that — **1.** I received the funds directly, or t hey were applied a credit to my (or, for parent PLUS borrowers, the student’s) school account to pay the amount owed to the school. **2.** I (or, for parent PLUS borrowers, the student) did not attend the school , withdrew, was terminated from the school within th e time from that would entitle me to a refund of some or all of my loan funds. Except as provided in Section 2, Items 7 through 11, I have not received this refund, or any benefit of a refund to which I am entitled, from the school or any third party. **3.** I have read and agree to the terms and conditions for loan discharge, as specified in Section 7. 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 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** ___ ___ - ___ _

__ -
_ _ _ _ _ _ _ _ _ ___Page 3 of 4 

### SECTION **5 : 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 atta ched pages . If a refund is owed for more than one student or from more than one school, use separate forms for each student or school . **Return the completed form and any attachments**  **to the address shown in Section 9**  **.** 

### 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 Dir ect 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 Consolidatio n Loans.  **Loan discharge** due to an unpaid refund cancels your obligation (and any endorser’s obligation, if applicable) to repay the portion of you loan t hat should have been refunded. Any accrued interest and other charges on the amount of the unpaid refun d will also be discharged, and you will be reimbursed for any amount that you have repaid that exceeds the remaining balance of the loan after the discharge. For consolidation loans, only the amount of the unpaid refund that was included in the consolidati on loan will be discharged . 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 w hom a parent borrower obtained a Direct PLUS Loan or Federal PLUS Loan.  **Program of study** means the instructional program leading to a degree or certificate in which you (or, for parent PLUS borrowers, the student) were enrolled.  **Third party** refers to any e ntity 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 **7 :**  **TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON UNPAID REFUND** 

 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 unpaid refund, 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. 

### SECTION **8 : 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.)Page 4 of 4 

### SECTION **12 : 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) . Particip ating 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 princip al 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 an d/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 p ermit 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 record s 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 reportin g 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, d isclosures 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 stat uses, 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. Chapte r 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 -0058. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searchi ng 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(l)(4), or 685.216(c) ) . If you have comments or concerns regarding the status of your individual submission of this form, **contact your loan hol der(s) (see**  **Section 8) directly.**