OMB Control Number 1845 - XXXX Form Under Review Expiration Date XX/XX/20XX **Third Party Servicer Data Fo**  **rm** 1. What is the legal name of this company /corporation? 2. Does the compan y have another name such as a trade name or a d/b/a name, under which the compan y conduct s business?  Yes  No If yes, please provide the name(s): 3. When did the company begin conducting business as a third part y servicer on behalf of Title IV , HEA institutions ? 4. What name does the company file the required annual compliance audit report that covers the compan y’s administration of an y aspect of an institution’s participation in the Title IV, HEA programs for all institutions with which the company contracts with? 5. What is the company ’s Dun & Bradstreet (DUNS) number? 6. Who are the owner/owners of this compan y? If you need more space, please attach an additional sheet and include the following for each owner : Name (include prefix, such as Mr., Ms., Dr.) Job Title Business Street Address City State and Zip ____/____/________

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Telephone number (including area code) Fax number (including area code) E - ma il Address 7. Who is completing this form? Name (include prefix, such as Mr., Ms., Dr.) Job Title Telephone number (including area code) E - ma il Address 8. Who is the highest ranking officer (CEO / COO/P resident) of this compan y ? Name (include prefix, such as Mr., Ms., Dr.) Job Title Business Street Address City State and Zip**Page 3**  **of 8** 

Telephone number (including area code) Fax number (including area code) E - ma il Address 9. Does this compan y have a web site (or home page) on the Internet?  Yes  No If yes, list the electronic address (URL). 10. Whom should we contact at this company should we have questions regarding information on this form or need to respond to an institutional inquiry? Name (include prefix, such as Mr., Ms., Dr.) Job Title Telephone number (including area code) Fax number (including area code) E - ma il Address**Page 4**  **of 8** 

11.  Check here if this company maintains more than one phy sical location (mailing address, processing center, etc . ) and provide the primary contact person, address, and phone number for each location occupied. If you need more space, please attach an additional sheet and include the following for each entity : Name (primary

contact person, include prefix, such as Mr., Ms., Dr.) Street Address City State and Zip Telephone number (including area code) Purpose of Location ( mailing address, processing center, etc . ) 12. Id entify

the ownership structure of this company :  Corporation

– publicly traded  Corporation

– not publicly traded  Partnership  Sole Proprietorship 13.  Check here if this company is affiliated with any

other company , corporation , or organization (own or is owned b y , regardless of percentage or contracts with ) and provide the name of the entit y, primary contact person, phone number, and e - mail below. If you need more space, please attach an additional sheet and include the following for each entity : Com pany/Corporation/Organization name Name (primary

contact’s name, include prefix, such as Mr., Ms., Dr.) Telephone number (including area code)**Page 5**  **of 8** 

Fax number (including area code) E - ma il Address Description of Relationship with Entity Description of Relation ship with the entity listed above.

14. Please indicate the Title IV, HEA services this company performs on behalf of clients :  Process student financial aid applications  Perform need anal ys is  Determine student eligibility and related activities (R2T4, SAP, Verification, Professional Judgment, Dependency

Override, etc.)  Certify loan applications  Process output documents  Receive, disburse, or deliver Title IV, HEA program funds (via check, EFT, debit card, etc.)  Conduct activities required by the provisions governing student consumer information services  Prepare and/or certify

request for advance or reimbursement funding  Lo an servicing and collection

– Federal Perkins L oans  Lo an ser

vicing and collection

– other Title IV, HEA Loans  Prepare and submit notices and applications required under 34 CFR part 600 and subpart B of the Higher Education Act  Prepare Fiscal Operations Reports and Applications to Participate (FISAP)  Enrollme nt Reporting**Page 6**  **of 8** 

 Provide Student L oan Default Prevention/Management services ( collect data, contact borrowers, provide counseling, initiate deferment/forbearances, skip tracing, contact lenders, etc. )  Fiscal reconciliation of Title IV, HEA program accounts  Provide on - site staffing  Other, please describe:**Page 7**  **of 8** 

15. Provide the names and OPE ID numbers for each client for whom this company contract s with to perform an y function that is the institution’s responsibility under the Title IV , HEA programs. If you need more space, please attach an additional sheet and include the following for each client : OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education OPE ID Name of College, University, Institution of Higher Education**Page 8**  **of 8** 



### I hereby **certify that, to the best of my knowledge and belief, all information in this document is true and correct. I understand that if my company provides false or**  **misleading information, the Department considers this to be a breach of the fiduciary standard of**  **conduct and may terminate the servicer’s eligibility to contract with any institution to administer any aspect of an institution’s**  **participation in the Title IV , HEA**  **programs. I also understand that I may be**  **subject to a fine of not more than $25,000 or i mprisonment of not more than five**  **years, or both, for misinformation that is material to receipt and stewardship of federal student financial aid funds.**  Signature of Individual completing this form: Date Signature of President/CEO/COO : (include prefix, such as Mr., Ms., Dr.) Date 

### Please attach a copy of **this company’s organizational chart with employee**  **names and titles and return this form to: Third Party Servicer Oversight Group**  **U.S. Department of Education Kansas City School Participation Division**  **1010 Walnut Street; Suite 336 Kansas City, MO 64106**  **(816) 268 –**  **0543 fsapc3rdpartyserviceroversight@ed.gov**  According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection o f information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845 - XXXX . Public reporting burden for this collection of information is estimated to average 75 minutes per respons e, 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 retain the benefit to contract with eligible institutions pursuant to 34 C.F.R. § 668.25. If you have comments or concerns regarding the status of your individual submission of this form, please contact the Third Party Servicer Oversight Group directly at (816) 268 - 0543 or fsapc3rdpartyserviceroversight@ed.gov .