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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 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: REFUND INFORMATION

Before responding, carefully read the entire form, including Section 5, 6, and 7 of 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 – First 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 for 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 loan 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 discharges, refunds, 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 received 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 amount 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, for 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.

SECTION 4: BORROWER ASSIGNMENT, CERTIFICATIONS, 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 certify that—

1. I received the funds directly, or they 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 the 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 ___ ___ - ___ ___ - ___ ___ ___ ___
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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 attached 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 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.

 Loan discharge due to an unpaid refund cancels your 

obligation (and any endorser’s obligation, if applicable) 

to repay the portion of you loan that should have been 

refunded. Any accrued interest and other charges on the 

amount of the unpaid refund 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 

consolidation 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 whom 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 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 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.)
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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). 

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 

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(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 holder(s) (see 

Section 8) directly.