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LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION 

(UNAUTHORIZED SIGNATURE/UNAUTHROZED PAYMENT)

William D. Ford Federal Direct Loan (Direct Loan) Program

Federal Family Education Loan (FFEL) Program

OMB No. 1845-0058

DRAFT FORM

Exp. Date XX/XX/XXXX

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any 

accompanying document is subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal 

Code and 20 U.S.C. 1097.

SECTION 1: BORROWER IDENTIFICATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN

Name

Address

City, State, Zip

Telephone – Primary

Telephone – Alternate

E-mail (optional)

___ ___ ___ - ___ ___ - ___ ___ ___ ___

____________________________________

____________________________________

____________________________________

( _______ ) _______ - _____________

( _______ ) _______ - _____________

____________________________________

SECTION 2: UNAUTHORIZED SIGNATURE/UNAUTHROIZED PAYMENT INFORMATION

1. You are applying for this loan discharge as a:

Student borrower – Skip to Item 4.

Parent borrower – Continue to Item 2.

2. Student Name (Last, First, MI):

_________________________________________

3. Student SSN:

___ ___ ___ - ___ ___ - ___ ___ ___ ___

4. School Name:

_________________________________________

5. School Address (street, city, state, zip code):

_________________________________________

_________________________________________

6. Dates of attendance at the school:

___ ___ - ___ ___ - ___ ___ ___ ___ to 

___ ___ - ___ ___ - ___ ___ ___ ___

7. Which document(s) was signed without your 

authorization? If you select boxes “a”, “b”, or “c”, 

skip to Item 12. If you select boxes “d”, “e”, “f”, or 

“g’, continue to Item 8.

a. Loan application

b. Promissory note

c. Master promissory note

d. Combined application/promissory note

e. Loan check

f. Electronic funds transfer authorization

g. Master check authorization

8. Did you (or, for a parent PLUS borrower, the student) 

ever receive any money from the school, or did the 

school ever reduce the amount of money that you (or, 

for a parent PLUS borrower, the student) owed to the 

school?

Yes – Continue to Items 9 - 10.

No – Skip to Item 11.

Don’t know – Continue to item 11.

9. One what date did the school return money or reduce 

the amount owed?

___ ___ - ___ ___ - ___ ___ ___ ___

10. What amount did the school return or in what amount 

did the school reduce the amount owed? 

$___________________________________________

11. How did you (or, for a parent PLUS borrower, the 

student) pay the tuition and fees owed to the school?

____________________________________________

____________________________________________

12. Provide the following about the person who signed 

the name on the document(s) identified in Item 7. 

Write “Don’t Know” if you do not know the 

name/position of the person:

a. Name: ___________________________________

b. Position: _________________________________
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SECTION 2: UNAUTHORIZED SIGNATURE/UNAUTHROIZED PAYMENT INFORMATION (CONTINUED)

13. Explain the circumstances under which the person 

identified in Item 12 signed your name on the 

documents identified in Item 7:

____________________________________________

____________________________________________

14. Did you (or, for a parent PLUS borrower, the student) 

make any monetary claim with, or receive any 

payment from, the school or any third party (see 

definition in Section 6) in connection with enrollment 

or attendance at the school?

Yes – Continue to Items 15– 18.

No – Skip to Item 18.

Don’t Know – Skip to Item 18.

15. What is the name, address, and phone number of the 

party with whom the claim was made or from whom 

payment was received?

a. Name: ________________________________

b. Address: 

_________________________________________

_________________________________________

c. Phone number: 

( _______ ) _______ - _____________

16. What are the amount and the status of the claim?

a. Amount: $_____________________________

b. Status: _______________________________

17. What was the amount of any payment received? If 

none, write “none”. $______________________

18. Did the holder of your loan receive any money back (a 

refund) from the school on your behalf?

Yes – Continue to Items 19 – 20 and submit this 

form with documentation of your signature.

No – Submit this form with documentation of your 

signature.

Don’t know. Submit this form with documentation 

of your signature.

19. What was the amount of the refund?

$________________________________________

20. Explain why the money was refunded:

____________________________________________

____________________________________________

Documentation of your signature is required.

You must attach documents containing four other samples of your signature in addition to the signature on this 

application. At least two of these samples must clearly show that your signatures were within one year before or 

after the date of the documents on which someone else signed your name. Examples of documents that would 

include both a signature and the date of the signature include—but are not limited to—cancelled checks, tax 

returns, and driver’s licenses. If you do not provide these samples, you cannot be considered for a loan discharge.

SECTION 3: BORROWER ASSIGNMENT, CERTIFICATIONS, AND AUTHORIZATION

 I certify that—

1. I am applying for a discharge of my Direct Loan or FFEL Program loan(s) because the loan application, promissory 

note, combined application/promissory note, loan disbursement check, electronic funds transfer authorization, 

or master check authorized were not authorized for the reasons stated in this application.

2. I did not sign any of the documents I selected in Item 7.

3. I have read and agree to the terms and conditions for loan discharge, as specified in Section 7.

4. Under the penalty of perjury, all of the information I have provided on this application and in any accompanying 

documentation is true and accurate to the best of my knowledge and belief.

 I hereby assign and transfer to the Department and right to a refund on the amount discharge that I may have from 

the school identified in Section 2 of this form and/or any owners, affiliates, or assignees of the school, and from any 

third party that may pay claims for a refund because of the actions of the school, up to the amount discharged by 

the Department on my loan(s).

 I authorize the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my 

request or my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future 

number that I provide for my cellular telephone or other wireless device using automated telephone dialing 

equipment or artificial or prerecorded voice or text messages.

Borrower Signature _______________________________________________ Date ___ ___ - ___ ___ - ___ ___ ___ ___
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SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM

When completing this form, type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only 

numbers. Example: February 10, 2014 = 02-10-2014. If you need more space to answer any of the items, continue on 

separate sheets of paper and attach them to this form. Indicate the number of the Item(s) you are answering and 

include your name and social security number (SSN) on all attached pages. Return the completed form and any 

attachments to the address shown in Section 8.

SECTION 6: DEFINITIONS

 The William D. Ford Federal Direct Loan (Direct Loan) 

Program includes Federal Direct Stafford/Ford (Direct 

Subsidized) Loans, Federal Direct Unsubsidized 

Stafford/Ford (Direct Unsubsidized) Loans, Federal Direct 

PLUS (Direct PLUS) Loans, and Federal Direct 

Consolidation (Direct Consolidation) Loans.

 The Federal Family Education Loan (FFEL) Program

includes Federal Stafford Loans (both subsidized and 

unsubsidized), Federal Supplemental Loans for Students 

(SLS), Federal PLUS Loans, and Federal Consolidation 

Loans.

 The holder of your Direct Loan Program loan(s) is the 

U.S. Department of Education (the Department). The 

holder of your FFEL Program loan(s) may be a lender, a 

guaranty agency, or the Department.

 Unauthorized signature means that the school, without 

the borrower’s authorization, signed the borrower’s 

name on the loan application or promissory note.

 Unauthorized payment means that the school, without 

the borrower’s authorized, endorsed the borrower’s loan 

check or signed the borrower’s authorized for electronic 

funds transfer or master check, and did not give the loan 

proceeds to the borrower or apply the loan proceeds to 

charges owed by the student to the school.

 Loan discharge due to an unauthorized signature on a 

loan application or promissory note cancels your 

obligation (and any endorser’s obligation, if applicable) 

to repay the remaining portion on a Direct Loan or FFEL 

Program loan, and qualifies you for reimbursement of 

any amounts paid voluntarily though forced collection on 

the loan. Loan discharge due to an unauthorized 

signature on a loan check electronic funds transfer 

authorization, or master check authorization applies only 

to the amount of the unauthorized payment. For 

consolidation loans, only the amount of the underling 

loans associated with the document listed in Item 6 will 

be considered for discharge. The loan holder reports the 

discharge to all credit reporting agencies to which the 

holder previously reported the status of the loan.

 The student (as in, “or, for parent PLUS borrowers, the 

student”) refers to the student for whom a parent 

borrower obtained a Federal PLUS Loan or Direct PLUS 

Loan.

 Third party refers to any entity that may provide 

reimbursement for a refund owed by the school, such as 

a State or other entity offering a tuition recovery 

program or a holder of a performance bond.

SECTION 7: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION

 I will provide, upon request, testimony, a sworn 

statement, or other documentation reasonably available 

to me that demonstrates to the satisfactory of the U.S. 

Department of Education (the Department) or its 

designee that I meet the qualifications for loan discharge 

based on false certification, or that supports any 

representation that I made on this form or any 

accompanying documents.

 I agree to cooperate with the Department or the 

Department’s designee in any enforcement action 

related to this application.

 I understand that this request may be denied, or my 

discharge may be revoked, if I fail to provide testimony, a 

sworn statement, or documentation upon request, or if I 

provide testimony, a sworn statement, or documentation 

that does not support the material representation that I 

have made on this form or on any accompanying 

documents.

 I further understand that if my loan is discharged based 

on any false, fictitious, or fraudulent statements that I 

knowingly made on this form or on any accompanying 

documents, I may be subject to civil and criminal 

penalties under applicable federal law.

SECTION 8: WHERE TO SEND THE COMPLETED REQUEST

Return the completed form and any required 

documentation to:

(If no address is shown, return to your loan servicer.)

If you need help completing this form, call:

(If no telephone number is shown, call your loan 

servicer.)
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SECTION 12: IMPORTANT NOTICES

Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 

552a) requires that the following notice be provided to 

you:

The authorities for collecting the requested information 

from and about you are §421 et seq. and §451 et seq. of 

the Higher Education Act of 1965, as amended (20 U.S.C. 

1071 et seq. and 20 U.S.C. 1087a et seq.) and the 

authorities for collecting and using your Social Security 

Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 

U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b). 

Participating in the Federal Family Education Loan (FFEL) 

Program or the William D. Ford Federal Direct Loan (Direct 

Loan) Program and giving us your SSN are voluntary, but 

you 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 and/or Direct Loan Programs, 

to permit the servicing of your loan(s), and, if it becomes 

necessary, to locate you and to collect and report on your 

loan(s) if your loan(s) becomes delinquent or defaults. 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 caseby-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 private 

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 eligibility 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 history 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 to efficiently submit student 

enrollment statuses, 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 witness 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 members 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 

provided 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 valid OMB control number. The valid 

OMB control number for this information collection is 

1845-0058. Public reporting burden for this collection of 

information is estimated to average 30 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 obtain or retain a benefit (34 

CFR 682.402(e)(3), or 685.215(c)). If you have comments 

or concerns regarding the status of your individual 

submission of this form, contact your loan holder(s) (see 

Section 8) directly.