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LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION 

(DISQUALIFYING STATUS)

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: DISQUALIFYING STATUS INFORMATION

To qualify for a loan discharge based on false certification due to a disqualifying status you (or, for a parent PLUS 

borrower, the student) must have been unable—at the time the school originated or certified your loan—to meet the 

legal requirements for employment in your state of residence (or, for a parent PLUS borrower, the student’s state of 

residence) in the occupation for which the program of study was intended.

1. You are applying for this loan discharge as a:

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. Dates of attendance at the school:

___ ___ - ___ ___ - ___ ___ ___ ___ to 

___ ___ - ___ ___ - ___ ___ ___ ___

7. Name of the program of study that you (or, for a 

Parent PLUS borrower, the student) were enrolled 

in when the school certified or originated the loan 

that you are requesting to have discharged:

_________________________________________

8. Indicate your disqualifying status by checking the 

appropriate box(es) below:

Age

Physical condition

Mental condition

Criminal record

Other (specify): _______________________

9. You must provide documentation to prove that 

you had the disqualifying status indicated in Item 

8. You must also document the state legal 

requirements for employment that you (or, for a 

parent PLUS borrower, the student) could not be 

meet. Provide a citation to the specific state law 

or regulation below, or attach a copy of the law or 

regulation to your application with the 

documentation of your disqualifying status. 

_________________________________________

_________________________________________

10. Before certifying or originating the loan, did the 

school ask you (or, for a parent PLUS borrower, 

the student) if the disqualifying status in Item 8 

existed?

Yes

No

Don’t Know
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11. Did you (or, for a parent PLUS borrower, the 

student) inform the school of the disqualifying 

status before the loan was certified or originated?

Yes

No

12. 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 16 - 18

No – Submit this form and documentation to 

the loan holder in Section 8.

Don’t Know – Submit this form and 

documentation to the loan holder in Section 8.

13. 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: 

( _______ ) _______ - _____________

14. What are the amount and the status of the claim?

a. Amount: $_____________________________

b. Status: _______________________________

15. What was the amount of any payment received? 

If none, write “none”.

$________________________________________

16. Did the holder of your loan receive any money 

back (a refund) from the school on your behalf?

Yes - Continue to Item 13

No – Skip to Item 15

Don’t Know – Skip to Item 15

17. What was the amount of the refund?

$________________________________________

18. Explain why the money was refunded: 

_________________________________________

_________________________________________

_________________________________________

SECTION 3: BORROWER ASSIGNMENT, CERTIFICATIONS, 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 ___ ___ - ___ ___ - ___ ___ ___ ___
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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. 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 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 (disqualifying 

status) 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 

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 Federal PLUS Loan or Direct 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.

 Origination and certification are steps in a school’s 

processing of a loan. In the Direct Loan Program, a loan is 

originated when the school creates an electronic loan 

origination record after determining that the borrower 

meets all loan eligibility requirements. In the FFEL 

Program, a loan is certified when the school signs a loan 

application or submits an electronic loan record to the 

lender or guaranty agency after determining that the 

borrower meets all loan eligibility requirements.

 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 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.

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 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. 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(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.