**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 requirement s 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 st udent s admitted or enrolled at the school. Throughout this Applicant Self - Certification, “you ” and “ your ” refer to the applicant who is applying for the loan. T he 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**
 

### F ree or low er- cost Title IV federal, state, or school student financial a id 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 low er- cost f inancial 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 sc hool’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**  **f inancial 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 enrollme nt covered by the loan $____________________ C. Difference between amounts A and B **W ARNING**  : If you borrow more than th e amount on line C , you risk reducing your eligibility for free or low er- cost federal, state, or school financial aid . $__________

__________ **SECTION 3**  **: APPLICANT INFORMATION Enter or correct the information below.**  Full Name and A ddress of School ____________________________________

_________________________ ___________________________________________ Applicant Name (last, first, MI) ___________________________________________________ Date of Birth (mm/dd/yyyy) _____/_____/__________ Permanent Street Address ________________________________________

________ ___________

_______ City, Sta te , 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 Appl icant** 

_______________________________________________ _____________________ **Date** (mm/dd/yyyy)

_______________________ OMB No. 1845 - 0101 Form Approved Exp. Date 02 - 28 - 2013 

# Priv **ate Education Loan Ap**  **plicant Self**  **- Certification**  This space for lender use only**12/21/2012**



### SECTION **5 : DEFINITIONS**  **Cost of attendance** is an estimat e of tuition and fees, room and board, transportation , and oth er 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), pr ivate , 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 fina ncial assistance is dete rmined by the school and may be obtained from the school’s financial aid office. A **lender i** s 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 pr ivate 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 **privat e 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 direc tly 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 i s 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 t he Federal Pell Grant Program , the Academic Competitiveness Grant (ACG) Program, the Federal Supplemental Educational Opp ortunity 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 Fe deral Perkins Loan Program, the National Science and Mathematics Access to Retain Talent Grant (National SMART Grant) Program, and the Teacher Education Assistance for Colleg e 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 REDUC TION 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 dat a 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.**