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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 p romissory 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 th e 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:

_____

____ ________________________Page 2 of 4 

### 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 s ubmit 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 signa ture 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 AUTHO**  **RIZATION**  **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 ag ree 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 a nd 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 reque st 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**

___ ___ - ___ ___ - ___ ___ ___ ___Page 3 of 4 

### 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 **: DEFINI** **TIONS**
 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 Fam ily 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 a pplicable) 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 elect ronic 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 d ischarge . 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 mater ial 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 documen ts, 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.)Page 4 of 4 

### 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 se rvicing 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 informati on 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 poss ible 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 agenci es, 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 guara nty 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 viol ation 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 discipli nary 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 vali d 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, gath ering 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 conce rns regarding the status of your individual submission of this form, **contact your loan holder(s) (see Section 8) directly.**