12/21/2012

60 Day Comment Period

________________________________________________________________________________________________

Important: Pursuant to Section 155 of the Higher Education Act of 1965, as amended, (HEA) and to satisfy the requirements of Section 128(e)(3) of the Truth in 

Lending Act, a lender must obtain a self-certification signed by the applicant before disbursing a private education loan. The school is required on request to provide 

this form or the required information only for students admitted or enrolled at the school. Throughout this Applicant Self-Certification, “you” and “your” refer to the 

applicant who is applying for the loan. The applicant and the student may be the same person. 

Instructions: Before signing, carefully read the entire form, including the definitions and other information on the following page. Submit the signed form 

to your lender. 

SECTION 1: NOTICES TO APPLICANT 

 Free or lower-cost Title IV federal, state, or school student financial aid may be available in place of, or in addition to, a private 

education loan. To apply for Title IV federal grants, loans and work-study, submit a Free Application for Federal Student Aid 

(FAFSA) available at www.fafsa.ed.gov, or by calling 1-800-4-FED-AID, or from the school’s financial aid office.

 A private education loan may reduce eligibility for free or lower-cost federal, state, or school student financial aid. 

 You are strongly encouraged to pursue the availability of free or lower-cost financial aid with the school’s financial aid office. 

 The financial information required to complete this form can be obtained from the school’s financial aid office. If the lender has 

provided this information, you should contact your school’s financial aid office to verify this information and to discuss your 

financing options.

SECTION 2: COST OF ATTENDANCE AND ESTIMATED FINANCIAL ASSISTANCE 

If information is not already entered below, obtain the needed information from the school’s financial aid office and enter it on the appropriate line. Sign 

and date where indicated.

A. Student’s cost of attendance for the period of enrollment covered by the loan $____________________

B. Estimated financial assistance for the period of enrollment covered by the loan $____________________

C. Difference between amounts A and B 

WARNING: If you borrow more than the amount on line C, you risk reducing your eligibility for 

free or lower-cost federal, state, or school financial aid. 

$____________________

SECTION 3: APPLICANT INFORMATION 

Enter or correct the information below. 

Full Name and Address of School ________________________________________________________________________________________________________ 

Applicant Name (last, first, MI) ___________________________________________________ Date of Birth (mm/dd/yyyy) _____/_____/__________

Permanent Street Address __________________________________________________________________ 

City, State, Zip Code __________________________________________________________________ ____________________ 

Area Code / Telephone Number Home ( ) ____________________________ Other ( ) ____________________________ 

E-mail Address________________________________________________________________________________________

Period of Enrollment Covered by the Loan (mm/dd/yyyy) From _____ / _____ / _______ to _____ / _____ / _______ 

If the student is not the applicant, provide the student’s name and date of birth. 

Student Name (last, first, MI) ____________________________________________________ Student Date of Birth (mm/dd/yyyy) _____/_____/__________

SECTION 4: APPLICANT SIGNATURE 

I certify that I have read and understood the notices in Section 1 and, that to the best of my knowledge, the information provided on this form is true and correct. 

Signature of Applicant ____________________________________________________________________ Date (mm/dd/yyyy) _______________________ 

OMB No. 1845-0101

Form Approved

Exp. Date 02-28-2013

Private Education Loan 

Applicant Self-Certification 

This space for lender use only
12/21/2012

SECTION 5: DEFINITIONS

Cost of attendance is an estimate of tuition and fees, room and board, transportation, and other costs for the period of enrollment covered by the loan, as 

determined by the school. A student’s cost of attendance may be obtained from the school’s financial aid office.

Estimated financial assistance is all federal, state, institutional (school), private, and other sources of assistance used in determining eligibility for most Title IV 

student financial aid, including amounts of financial assistance used to replace the expected family contribution. The student’s estimated financial assistance is 

determined by the school and may be obtained from the school’s financial aid office.

A lender is a private education lender as defined in Section 140 of the Truth in Lending Act and any other person engaged in the business of securing, making, or 

extending private education loans on behalf of the lender.

A period of enrollment is the academic year, academic term (such as semester, trimester, or quarter), or the number of weeks of instructional time for which the 

applicant is requesting the loan. 

A private education loan is a loan provided by a private education lender that is not a Title IV loan and that is issued expressly for postsecondary education 

expenses, regardless of whether the loan is provided through the school that the student attends or directly to the borrower from the private education lender. A 

private education loan does not include (1) An extension of credit under an open-end consumer credit plan, a reverse mortgage transaction, a residential mortgage 

transaction, or any other loan that is secured by real property or a dwelling; or (2) An extension of credit in which the school is the lender if the term of the extension 

of credit is 90 days or less or an interest rate will not be applied to the credit balance and the term of the extension of credit is one year or less, even if the credit is 

payable in more than four installments.

Title IV student financial aid includes the Federal Pell Grant Program, the Academic Competitiveness Grant (ACG) Program, the Federal Supplemental Educational 

Opportunity Grant (FSEOG) Program, the Leveraging Educational Assistance Partnership (LEAP) Program, the Federal Family Education Loan Program (FFELP), 

the Federal Work-Study (FWS) Program, the William D. Ford Federal Direct Loan (Direct Loan) Program, the Federal Perkins Loan Program, the National Science 

and Mathematics Access to Retain Talent Grant (National SMART Grant) Program, and the Teacher Education Assistance for College and Higher Education 

(TEACH) Grant Program. To apply for Title IV federal grants, loans, and work-study, submit a Free Application for Federal Student Aid (FAFSA), which is available at 

www.fafsa.gov, by calling 1-800-4-FED-AID, or from the school’s financial aid office.

SECTION 6: PAPERWORK REDUCTION NOTICE

Paperwork Reduction Notice: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information 

unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0101. The time required to 

complete this information collection is estimated to average 0.25 hours (15 minutes) per response, including the time to review instructions, search 

existing data resources, gather and maintain the data needed and complete and review the information collection.

If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. 

Department of Education, Washington, DC 20202-4651 

If you have any comments or concerns regarding the status of your individual submission of this form, contact your lender.