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## LOAN DISCHARGE APPLICATION **: SCHOOL CLOSURE**  **William D. Ford Federal Direct Loan (Direct Loan) Program ,**  **Federal Family Education Loan (FFEL) Program** **, and Federal Perkins Loan 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 :**  **SCHOOL CLOSURE INFORMATION**  **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.** Closed School Name :

_________

_______ __ ____________

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

______________________ ___________________

_________________________________________ **6.** Dates of attendance at the closed school:

___ ___ - ___ ___ - ___ ___ ___ ___ to

___ ___ - ___ ___ - ___ ___ ___ ___ **7.** Name of the program you (or, for a parent PLUS borrower, the student) were enrolled in at the time the school closed:

_________________________________________ **8.** Did you (or, for a parent PLUS borrower, the student) complete the program of study **at the closed**  **school** ? Yes – You are not eligible for this discharge. No – Continue to Item 9 . **9.** Were you on an **approved** leave of absence when the school closed? Yes – Continue to Item 10, then skip to Item 17 . No – Skip to Item 11 . **10.** Provide the dates of the leave of absence:

___ ___ - ___ ___ - ___ ___ ___ ___ to

___ ___ - ___ ___ - ___ ___ ___ ___ **11.** Were you (or, for a parent PLUS borrower, the student) still enrolled in the program of study when the school closed? Yes – Skip to Item 17 . No – Continue to Item 12 . **12.** Did you (or, for a parent PLUS borrower, the student) withdraw from the school before the school closed? Yes – Skip to Item 17 . No – Continue to Item 13 . **13.** On what date did you withdraw from the school?

___ ___ - ___ ___ - ___ ___ ___ ___ **14.** Did you (or, for a parent PLUS borrower, the student) complete or are you in the process of completing the same or comparable program of study at another school? Yes – Complete Items 15 and 16, then continue to Item 17 . No – Skip to Item 17 . **15.** Did the other school give you (or, for a parent PLUS borrower, the student) credit for training received at the closed school by allowing transfer credits or hours earned at the closed school, or by any other means? Yes – Continue to Item 16 . No – Continue to Item 16 .Page 2 of 4

**16.** Were you (or, for a parent PLUS borrower, the student) required to start the program of study over from the beginning at the other school? Yes No **17.** Did the holder of your loan receive any money back (a refund) from the closed school on your behalf? Yes – Continue to Items 18– 19 . No – Skip to Item 20 . Don’t Know – Skip to Item 20 . **18.** What was the amount of the refund? $

________________________________________ **19.** Explain why the money was refunded:

_________________________________________

____________________________________ _____

_________________________________________ **20.** 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 21 – 23 No – Submit this form to the loan holder in Section 8. Don’t Know – Submit this form to the loan holder in Section 8. **21.** W hat 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: (

_______ )

_______ - _____________ **22.** What are the amount and the status of the claim? **a.** Amount : $

_____________________________ **b.** Status:

_______________________________ **23.** What was the amount of any payment received? If none, write “none”. $

________________

________________________ 

### SECTION **3 : BORROWER**  **CERTIFICATIONS , ASSIGNMENT,**  **AND AUTHORIZATION**  **I certify** that: **(1)** I received the Direct Loan, FFEL, or Perkins Loan Program loan funds directly, or as a credit that was applied to the amount owed to the school ; **(2)** I (or, if I am a parent PLUS borrower, the student) was enrolled at the school identified in Section 2 or on an **approved** leave of absence on the date that the school closed, or withdrew from the school not more than 120 days before it closed (or longer if the Department determines that exceptional circumstances related to the school’s closing justify an extension of this 120-day period ), and could not complete the program of study; **(3)** Due to school closure, I (or, if I am a parent PLUS borrower, the student) did not complete and am not in the process of completing the program or comparable program of study in which I was enrolled at the closed school at another school by transferring credits or hours earned at the closed school to another school, or by any other means by which I (or, if I am a parent PLUS borrower, the student) benefitted from training provided by the closed school ; **(4)** I have read and agree to the terms and conditions for loan disch arge, as specified in Section 7; **(5)** 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 U.S . Department of Education (the Department) any right to a refund on the amount discharged 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 cellul ar 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 na me and social security number (SSN) on all attached pages. **Return the completed form and any attachments**  **to the address shown in Section 8** **.** 

### SECTION 6 **: DEFINITIONS**   The **William D. Ford Federal Direct Loan (Direct Loan) Program**  includes Fe deral 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 Educatio n 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 **Federal Perkins Loan (Perkins Loan) Program** includes Federal Perkins Loans, National Direct Student Loans (NDSL), and National Defense Student Loans (Defense Loans).  The **date a school closed** is the date that the school stopped providing educational instruction in **all programs**  as determined by the Department.  **Dates of attendance** : The “to” date means the last date that you (or, for a parent PLUS borrower, the student) actually attended the closed school.  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 . The holder of your Perkins Loan Program loans may be a school or the Department.  **Loan discharge** due to school closure cancels your obligation (and any endorser’s obligation, if applicable) to repay the remaining portion on a Direct Loan, FFEL Program , or Perkins Program loan, and qualifies you for reimbursement of any amounts paid voluntarily though forced collection on the loan. For consolidation loans, only the amount of the underlying loans that were used to pay for 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 Direct PLUS Loan or Federal PLUS Loan.  **Program of study** means the instructional progra m 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 tuitio n recovery program or a holder of a performance bond. 

### SECTION **7 :**  **TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON SCHOOL CLOSURE**   I will provide, upon request, testimony, a sworn statement, or other documentation re asonably 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 school closure, or that supports any representation that I made o n 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 furth er 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 **9 : 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. , §451 et seq. and §461 et seq. of the Higher Education Act of 1965, as amended (20 U.S.C. 1071 et seq. , 20 U.S.C. 1087a et seq. , and 20 U.S.C. 1087aa 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 20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Education Loan (FFEL) Program, the William D. Ford Federal Direct Loan (Direct Loan) Program, or the Federal Perkins Loan (Perkins 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 th e 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 a nd 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 compl aints, 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 7 1. 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(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 8) directly.**