### What is a Preauthorized Debit **Account?** A Preauthorized Debit Account (PDA) is an account that gives your bank the authority to automatically deduct your defaulted Federal education debt payments from your checking/savings account.

**What are the b**  **enefits?** With PDA, your payments will always be made on time, you will save on postage fees, and you can choose a payment schedule that best suit s your financial budget while repaying your student aid debt.

**How do I e**  **stablish an a**  **ccount?** To establish an account, co mplete the Preauthorized Debit Applicat ion attached to this brochure. Then mail it to the address at the bottom of the application, along with a blank check or savings account authorization voucher on which you have written “VOID.” After your bank starts d educting your payments, an itemization of your defaulted Federal education debt transactions will appear on your bank statement.

**What a**  **mount will be d**  **ebited from m**  **y**
**a ccount?**  On the application, please indicate whether you want payments debited weekly, biwe ekly (once every two weeks), or monthly. The total amount deducted during a given month must be equal to or greater than the amount designated on your original repayment agreement , if a repayment agreement has been established

. **What if I want to c**  **ancel m**  **y PDA s**  **ervice?** To cancel your PDA service, just call the U.S. Department of Education’s Default Resolution Group at 1

- 800

- 621

- 3115. After cancellation, it may take seven (7) days to discontinue the electronic debiting service and there may be one more auto matic payment deduction from your checking or savings account.

**PLEASE NOTE:**

 Your bank name, voided check or savings account voucher , and your bank’s routing number are required to establish you r Preauthorized Debit Account. **Your personal information will b**  **e kept confidential.**

 **Make a copy of the completed application for your records, or enter**  **the information below and keep this**  **page :**  **Bank Name: _______________________**

**____ Checking Account #:** 

**________________ ____**  **Savings Account #:**

**_____________________ Routing Number:** 

Deduct payments of $___________ from my account. (The amount entered is the amount that will be debited weekly, biweekly or monthly, as indicated below.) 

### Weekly Circle a day: M T W Th F Biweekly Ent er start date from 1

- 28: ____ Monthly Ent er start date from 1

- 28: ____ ( Y our payment will be debited on the spe cific day or date you enter.) 

### Date Signed:________________________

*** * *** **To learn more about PDA ,**  **go to:**

www.myeddebt.com **PREAUTHORIZED DEBIT APPLICATION** Mail in this portion . . .

**Defaulted Federal Education Debt Account Number**  (this number appears on your monthly statement) **:** 

### I,

____________________________________

**Applicant’s Name**

**– (**  **please print )**  authorize my bank to deduct my defaulted Federal education debt payments automatically from the account designated below. **I understand that I must make regular monthly payments until I am notified that my Preauthorized**  **Debit Account A pplication has been processed.**  If at any time I decide to discontinue Preauthorized D ebit s , I will notify the U.S. Department of Education ’s Default Resolution Group at 1

- 800

- 621

- 3115. **Bank Name: ___________________________**

**________ Checking Account #: ____________________** 

**_________ Savings Account #:** 

**_____________________ _________**  **Routing Number:**

Deduct payments of $___________ from my account. (The amount entered is the amount that will be debited weekly, biweekly or monthly, as indicated below.) Weekly Circle a day: M T W Th F Biweekly Enter start date from 1

- 28: ____

__ Monthly Enter start date from 1

- 28: ____

__ ( Y our payment will be debited on the specific day or date you enter.) **SSN:**

**_________________________________________**

**______________________________ ___________ Appli**  **cant’s Signature Date**  **Daytime Phone: (_______) _______________________ Return this Application with voided check or savings**  **account voucher with routing number to:**

**PREAUTHORIZED DEBIT PROGRAM** 

**P.O. BOX 4139 GREENVILLE, TX 7540**  **3**

**- 4139** 

**6 0** 

**- DAY CLEARANCE DRAFT** **PRIVACY ACT NOTICE** The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authority for collecting the requested information from and about you are §428(b)(2)(A) et seq

. , §451 et seq. , and/or §461 et seq. of the Higher Education Act (HEA) of 1965, as amended ( 20 U.S.C. 1078(b)(2)(A) et seq. , 20 U.S.C. 1087a et seq. , and/or 20 U.S.C. 1087aa et seq. ) and the authorities for collecting and using your Social Security Number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Education Loan (FFEL) Program, William D. Ford Federal Direct Loan (Direct Loan) Program, and Federal Perkins Loan (Perkins) Program and giving us your SSN are voluntary, but yo u 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 Program, Direct Loan Program, and/or Perkins Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on y our loan(s) if your loan(s) become delinquent or in default. 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 case by 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 pr ivate 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 eligibi lity 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 his tory 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 efficiently to submit student enrollment status, 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 wi tness 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 m embers 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 provide d 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 currently valid OMB control number. The valid OMB control number for this information collection is 1845

- 0025. Public reporting burden for this collection of information is estimated to average 0.083 hours (5 minutes) per response, including time for reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and co mpleting and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit (U.S. Code 15 USC 1601 Consumer Credit Protection Act). **If you have any comments or concerns regarding the status**  **of your individual submission of this**  **Preauthorized Debit Application , write directly to:** 

**U.S. Department of Education Preauthorized Debit Program**  **P.O. Box 4139 Greenville, TX 75403** 

**- 4139** 

**6 0** 

**- DAY CLEARANCE DRAFT**  OMB No. 1845

- 0025 Form Approved Exp. Date xx/xx/xxxx