OMB Control Number 1845-XXXX 

Form Under Review 

Expiration Date 

XX/XX/20XX

Third Party Servicer Data Form

1. What is the legal name of this company/corporation?

2. Does the company have another name such as a trade name or a d/b/a name, under which the 

company conducts business?  Yes No

If yes, please provide the name(s):

3. When did the company begin conducting business as a third party servicer on behalf of Title 

IV, HEA institutions?

4. What name does the company file the required annual compliance audit report that covers the 

company’s administration of any 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 company? 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-mail Address

7. Who is completing this form?

Name (include prefix, such as Mr., Ms., Dr.)

Job Title 

Telephone number (including area code)

E-mail Address

8. Who is the highest ranking officer (CEO/COO/President) of this company?

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-mail Address

9. Does this company 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-mail Address
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11.  Check here if this company maintains more than one physical 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. Identify 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 by, regardless of percentage or contracts with) and provide the 

name of the entity, 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:

Company/Corporation/Organization name

Name (primary contact’s name, include prefix, such as Mr., Ms., Dr.)

Telephone number (including area code)
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Fax number (including area code) 

E-mail Address

Description of Relationship with Entity

 Description of Relationship 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 analysis

 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

 Loan servicing and collection – Federal Perkins Loans

 Loan servicing 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)

 Enrollment Reporting
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 Provide Student Loan 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:
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15. Provide the names and OPE ID numbers for each client for whom this company contracts

with to perform any 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
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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 imprisonment 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 of 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 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 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.