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### RAP 

## FINANCIAL DISCLOSURE FOR REASONABLE AND AFFORDABLE **REHABILITATION PAYMENTS William D. Ford Federal Direct Loan (Direct Loan) Program**  **Federal Family Education Loan (FFEL) Program**  OMB No. 1845

-0120 Form Approved Exp. Date 03/31/2017 **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. 10 97. 

### 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 **: HOUSEHOLD INCOME AND REASONABLE AND NECESSARY MONTHLY EXPENSES**  You have received this form because you requested the opportunity to rehabilitate your defaulted Direct Loan(s) and/or FFEL Program Loan(s) and objected t o the monthly payment amount your loan holder calculated using the 15 percent formula (15% of the amount by which your Adjusted Gross Income exceeds 150% of the poverty guideline amount applicable to your family size and stat e , divided by 12 )

. **Before completing this section**  **, carefully read the entire form, including the**  **instructions and definitions in Sections 5 ,**  **6 ,**  **and 7**

. Your loan holder will use the information you provide on this form to determine an alternative reasonable and affordable monthly payment amount. If you want to rehabilitate your defaulted loan(s) you must choose to make qualifying payments in either the p ayment amount calculated using the 15 percent formula or the alternative payment amount determined based on the information you provide on this form

. Once you choose the payment amount you want to make you must make 9 on

-time payments of that amount over the next 10 months. Provide the **monthly** income and expense information listed below. Do not include documentation of these sources of income or expenses unless requested to do so by your loan holder. Do not include your spouse’s income if your spouse does not contribute to your household income. You r loan holder has the authority to determine if the claimed amount of an y expense is reasonable and necessary

.

**MONTHLY INCOME** 1. Your employment income : $______________ 2. Spouse’s employment i ncome : $______________ 3. Child support payments received : $______________ 4. Social Security benefits: $______________ 5. Worker’s compensation: $______________ 6. Public assistance: $

______________ List type(s):

_______

___________

___ _____________ 7. Other income: $______________ Describe:

___________________ ___ ____ ____ ______ **8. Total Monthly Income**  **: $___** 

**_ ___**  **_ ___**  **___** (Sum of items 1 through 7) **MONTHLY EXPENSES** 9. Food: $______________ 10. Housing: $______________ 11. Utilities: $______________ 12. Basic communication : $______________ 13. Necessary m edical and dental: $______________ 14. Necessary i nsurance : $______________ 15. Transportation: $______________ 16. Dependent care: $______________ 17. R e quired child support / spousal support : $____

_______ ___ 18. Federal student loan payment s : $______________ 19. Private student loan payment s : $______________ 20. Other expenses: $______________ Describe:

___________________ ___ ______________ **21. Total Monthly Expenses**  **: $_____** 

**_ _**  **_____ __**  (Sum of items 9 through 20)Page 2 of 5 

### Borrower Name ________________________________ Borrower SSN:
___ ___ ___ - ___ ___ - ___ ___ ___ ___ 

### S **ECTION 3 :**  **FAMILY SIZE ,**  **ADJUSTED GROSS INCOME** **, AND SPOUSAL IDENTIFICATION Before completing this section, carefully read the entire form, including the instructions and definitions**  **in Sections 5 ,**  **6 ,**  **and 7**

. 1. Your family size: ____________ ( Note: Your family size includes you, your spouse, and your children (including unborn children who will be born before the end of the calendar year ), if the children will receive more than half their support from you. Your family size includes other people only if they live with you now, receive more than half their support from you now, and will continue to receive this support from you for the year for which you are certify ing your family size. Support includes money, gifts, loans, housing, food, clothes, car, medica l and dental care, and payment of college costs. ) 

### 2. Adjusted Gross Income (AGI) amount reported on your most recent IRS tax filing : $_________

_ _ [ **Optional** ] (Note: AGI is used to determine a reasonable and affordable rehabilitation payment amount using the 15 percent formula. You have the option to report AGI on this form in case you decide to accept the monthly payment amount determined using the 15 percent formul a, rather than the monthly payment amount determined using the income and expense information you provided on this form. If you choose the payment amount determined using the 15 percent formula, you will be required to submit documentation of your AGI to your loan holder.) 

### 3. Spouse’s Name: _______________________________ 4. Spouse’s SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ (Note: Your spouse’s name and Social Security Number are only required if you are requesting rehabilitation of a Direct Consolidation Loan or Federal Consolidation Loan that was made jointly to you and your spouse ) 

### SECTION 4: UNDERSTANDING **S , CERTIFICATION**  **S , AND AUTHORIZATION**  **Before completing this section, carefully read the entire form, including the instructions an d def** **initions in Sections 5, 6** **, and 7** 

.  **I understand that:** 1. I have received this form because I requested the opportunity to rehabilitate my defaulted Direct Loan(s) and/or FFEL Program Loan(s) and objected to the reasonable and affordable monthly payment amount calculated using the 15 percent formula. 2. My loan holder will calculate an alternative reasonable and affordable monthly payment amount that will be based solely on the information I provide on this form and , if requested, supporting docume ntation. 3. If I do not accept the monthly payment amount calculated using either the 15 percent formula or based on the income and expenses information I provide on this form , the loan rehabilitation process cannot proceed and I will be required to repay my defaulted loans with payment amounts determined by my loan holder in accordance with the terms of the loan and applicable law. 4. If I do not provide any supporting documentation requested by my loan holder by the deadline specified by my loan holder, my request for loan rehabilitation will not be considered any further

. 5. If I have a defaulted Direct C onsolidation Loan or Federal Consolidation Loan that was made jointly to me and my spouse , both borrowers must request a reasonabl e and affordable payment rehabilitation payment determination, and our signatures below serve as that request. 6. If I previously rehabilitated a defaulted loan on or after August 14, 2008, I may not rehabilitate that same loan if I default on that loan again

.  **I certify that:** 1. The information that I have provided on this form is true and correct. 2. Upon request, I will provide additional documentation to my loan holder to support the information I have provided in this form.
 **I authorize** the loan holder to whic h 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 wi reless device using automated telephone dialing equipment or artificial or prerecorded voice or text messages. **Spouse’s Signature**

______________________________________________ _____ _ **Date**

__

________ __ ___ **(If you entered spousal identification**  **information in Section 3)** 

### Borrower Signature

_____________________________________________ _____ __ **Date**

___

____ ___ _____Page 3 of 5 

### SECTION **5: INSTRUCTIONS**
 

### If you are not completing this form electronically, type or print using dark ink. Enter dates as month

day

-year (mm

- dd

-yyyy). Use only numbers. Example: January 31, 2013 = 01

- 31

- 2013. Include your name and account number (s) for your defaulted loan(s) on any documentation that you are required to submit with this form. If you n eed help completing this form, contact your loan holder(s). **Return the completed form to the address shown in Section**  **8 .**   

### Monthly Income in Section 2 **(Items 1 –**  **7) .**  Your loan holder(s) may request supporting docu mentation for any income items: **E mployment**  **income** documentation ma y i n cl ud e a pa y st u b or a l ett er f ro m the e m p l o ye r st a t i n g the i n c o m e f ro m t ha t emp l o yer . **Child support, Social Security benefit ,**  **worker’s compensation or public assistance**  documentation may include copies of benefits checks or a benefits statement, a letter from a court, a governmental body, or the individual paying child support, specifying the amount of the benefit.
 **Public assistance:** Identify the type of public assistance received (See definition of “public assistance” in Secti on 6).
 **Other income:** Include any other income not covered in items 1

- 6 and i dentify the source of the income.  

### Monthly Expenses in Section 2 **( I**  **tems 9 -** **20) .**  Your loan holder(s) may request supporting documentation for any of these items. Do not include a single expense in more than one category. If you have no expenses under a category, enter 0 for that category.
 **Food:** Include the amount spent on food, even if purchased using the Supplemental Nutrition Assistance Program (SNAP) (food stam ps).
 **Housing:** Include the amount spent on housing and shelter, such as rent, required security deposits, and mortgage payments ( including principal, interest, taxes, and homeowner’s insurance).
 **Utilities** : Include the amount spent on housing

related utility bills, such as gas, electric, water, sewer, trash, and recycling.
 **Basic communication:** Include the amount spent on basic communication expenses, such as basic telephone and internet expenses.  **Medical and d**  **ental:** Include the amount spent on necessary medical and dental costs, such as medically necessary prescription and nonprescription medication, and medically necessary nutritional supplements. Do not include any costs relating to medical or dental insurance prem ium payments.
 **Insurance:** Include the amount spent on insurance, such as necessary renter’s, auto, medical, dental, or life insurance. Include any amounts paid toward insurance premiums, but do not include any amount that is deducted from your paycheck and reflected in the amount of income you listed under Monthly Income. Include homeowner’s insurance under Item 10 (Housing)

.  **Transportation:** Include the amount spent on basic transportation expenses such as gas, car loans, basic vehicle maintenance, and public transportation.
 **Dependent care:** Include the amount spent on care for children or other dependents in the household and other work

- relat ed expenses

.  **Legally required child support/ spousal support**  Include the amount spent on legally required child support and spousal support.
 **Federal student loan payment s**  **:** Include the total monthly amount paid on any federal student loan (s) , except the defa ulted loans you are trying to rehabilitate unless you are subject to mandatory withholding such as wage garnishment or Treasury offset ( i .e., your Social Security is being garnished). If you are subject to wage garnishment or Treasury offset include the amount that is collected from you monthly. (Include the amount of any payment, voluntary or otherwise.
 **Private student loan payment s**  **:** I nclude the total monthly amount paid on any private student loan (s) . Include any type of payment, voluntary or otherwise.
 **Other expenses:** Include the amount spent on any other necessary expense s not covered in i tems 9

- 19 and explain these expenses

. These other expenses will be considered only if the Department of Education determines that they should be considered

.Page 4 of 5 

### SECTION 6 **: DEFINITIONS** 
 

### T h e **F e**  **d e**  **r a**  **l F**  **a m**  **i l**  **y E**  **d u**  **ca t**  **i o**  **n L** **o a**  **n (**  **F F**  **EL )**  **P r** **og r** **a m**  i n c l u de s F e de ra l St a ffo rd Lo a n s ( bot h s ub s i d i ze d an d u n s ub s i d i z ed ) , F e de ra l P L U S Lo a n s, F e de ra l Con s o l i da t i o n Lo an s, a n d F e d e ra l S u pp l e m en t a l Lo a n s fo r Stud en t s ( S LS ).  

### The **W illi**  **a m**  **D .**  **Fo r** **d F**  **e d**  **e r** **a l**  **D ire** **c t**  **L o**  **a n**  **( D**  **ir ec** **t L** **o an**  **) P**  **ro g**  **r a**  **m** i n c l u d e s F ed e ra l D i re ct St a ffo rd/F o r d ( D i re ct S u b s i d i z ed ) Lo an s, F e d e ra l D i re ct Un su b s i d i ze d St a f

fo rd /F o r d ( D i re ct Un su b s i d i ze d ) Loa n s, F e de ra l D i rect PLU S ( D i re ct P L US ) Lo an s, a n d F ed e ra l D i re ct Co n s o l i da t i o n ( D i re ct Con s o li d a t i on ) Lo an s .  

### Rehabilitation o f you r defaulted l oa n o cc u rs on ly after y o u ha ve m a d e 9 voluntary, reasonable and affordable monthly p a y m e n t s within 20 days of the due date during 10 consecutive months a n d, fo r F F E L l o a n s, w h e n t h e l oa n h a s b ee n s o ld t o an e li g i b l e l e n d e r . W h e n yo u re h a b ili t a t e yo u r l oan s, yo u w ill re g a in a ll t h e b e nefi t s o f th e D i re ct Lo a n P rog ra m o r F F E L P ro g ram , i n c l ud i n g e li g i b ili ty fo r de fe r m en t s o r fo r b ear an c e s a n d eligibility for a re pa y m e n t p l a n w i t h a m on t h ly pa y m e n t a m o u n t b a se d o n yo u r i n c o m e . Yo u w ill a l s o re g a in e li g i b ili ty t o re c e i ve a d d i t i o n a l F e d e ra l stu d e n t a i d , i n c l ud i ng a d d i t i o n a l Fe de ra l st ud e n t l o an s . After a defaulted loan is rehabilitated, your loan holder will instruct any consumer reporting agency to which the default was reported to remove the default from your credit history.  

### Reasonable and **affordable payment amount** m e an s a monthly p ay m en t th a t is ba se d either on the 15 percent formula or o n i n fo r ma t i o n p ro v i d e d i n t h is fo r m a n d su p p o rt i n g d o cu m e n t a t i o n. It ca n n o t b e a pe rce n ta g e o f y ou r t ot al l o a n b a l a n c e o r ba se d o n i n fo r m a t i o n un re l a te d t o yo u r t ot a l fi n an c i a l c i rc um sta n ces .  

### The **15 percent formula** means fifteen percent of the amount by which your Adjusted Gross Income exceeds 150% of the poverty guideline amount that is applicable to your family size and state, divided by 12. Your minimum payment may not be less than $5.00.  

### T h e **loan h**  **o ld**  **e r**  o f a d e fa u l te d D i re ct Lo a n P ro g ra m l o a n (s ) is t h e U.S. D e pa rt m e n t of Education (the Department)

. T h e loan h o l d e r o f a d e fa u l te d F F E L P rog ra m l oa n (s ) ma y b e a g ua ran ty a g e n cy o r t h e D e pa rt m e n t
.  

### Public **assistance** means payments you receive under a federal or state program. These assistance programs include, but are not limited to, Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), Food Stamps/Supplemental Nutritional Assi stance Program (SNAP), or state general public assistance. 

### SECTION 7: **LOAN REHABILITATION AGREEMENT**
 

### To rehabilitate your loan, you must accept either the m onthly rehabilitation payment amount determined using the 15 percent formula, or the amount determined based on the monthly income, monthly expenses, and family size information that you provide on this form and on any requested supporting documentation

.  

### Your loan holder will provide you with a written loan rehabilitation agreem ent confirming your mont hly rehabilitation payment amount.  

### To accept the loan rehabilitation agreement, you must sign the agreement and return it to your loan holder.  

### During the loan rehabilitation period, the loan holder will limit contact with you on the loan being rehabilitated to collection activities that are required by law or regulation, and to communication that supports the rehabilitation.  

### If you do not accept either mont hly payment amount, your rehabilitation request will not be considered any further. 

### SECTION **8 : WHERE TO SEND THE COMPLETED**  **FINANCIAL DISCLOSURE FORM** 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 5 of 5 

### SECTION **9 : IMPORTANT NOTICES**  **P ri** **v a** **c y**  **Ac t**  **No tic** **e .**  T

h e Priva cy A ct o

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. Pa rt i c i pa t i n g in th e Fe de r a l F a mily E d u c a t i o n Lo a n (FF EL ) P rog ra m o r th e Willi a m D
. F o rd F e de ra l D i r e ct Loa n ( D i r e ct Loa n ) P rog ra m a n d g i v i n g u s you r SS N a re v o l u n t a ry, b u t yo u m u st p r ov i d e t h e re q ue ste d i n fo r m a t i on , i n c l ud i n g yo u r SSN , t o p a rt i c i pa te. T h e p r i n c i pa l p u rp o s e s fo r co ll e ct i n g t h e i n fo r m a t i o n o n t h is fo r m , i n c l u d i n g you r SS N , a re t o v e r i fy you r i d en t i ty, t o de te r m i n e you r e li g i b ili ty t o r e c e i v e a l o a n o r a be nefi t o n a l oa n (s u c h a s a d e fe r m e n t, fo r b e a ra n c e , d i sch a rg e, o r fo rg i ve ne ss ) u n d e r t h e F F E L a n d /o r D i r e ct Loa n P ro g ra m s, t o pe r m it t h e s e rv i c i n g of you r l o an (s) , a n d , if it be c o m e s n e c e ss a ry, t o l o c a t e yo u a n d t o co ll e ct a n d re po rt o n yo u r l o a n (s ) if you r l oan (s ) b e c o m e s d e l i n q u en t o r de fau l ts
. We a l s o u s e yo u r S S N a s a n a cco un t i d e n t i fi e r a n d t o pe r mit yo u t o a cc e s s your a cc o u n t i n fo r m a t i o n e l e ctr on i c a ll y . T h e i n fo r ma t i o n in yo u r file m a y b e d i sc l o s ed , o n a c a se by- c a s e b a s is o r u nd e r a co m p u t e r m a tc h i n g p rog ra m, to t h i r d pa rt i e s a s au t ho r i ze d u n d e r r ou t i n e u s e s in th e ap p ro p r i a t e syst em s of r e c o rd s not i c e s . T h e ro u t i n e us e s of t h is i n fo r ma t i o n i n c l ud e , bu t a r e n ot li m i t e d t o, i t s d i sc l o s u r e t o fe de ra l, st a t e , o r l o c a l a g e n c i e s, t o p r i v a te pa rt i e s s u c h a s r e l a t i v e s, p r e se n t a n d fo r me r e mp l oy e rs, bu s i ne s s a n d pe rso na l a ss o c i a t e s, t o c on s u m e r r e port i n g a g e n c i e s, t o fi n a n c i a l a n d e d u c a t i ona l i n st i t u t i on s, a n d t o g ua ran ty a g e n c i e s in o rd e r to v e r i f y you r i d e n t i ty, t o de te r mi n e you r e li g i b ili ty t o r e c e i ve a l o a n o r a b e n efit o n a l o a n , t o pe r m it th e s e rv i c i n g o r c o ll e ct i o n of yo u r l o an (s) , t o en fo rc e th e t e r m s of th e l o an (s) , t o i n v e st i g a t e po ss i b le frau d a n d t o v e r i fy c o m p li an ce w i t h fe d e r a l st u de n t fi n a n c i a l a id p ro g ra m re gu l a t i on s, o r t o l o c a t e yo u if yo u b e co m e de li nq u e n t in yo u r l o a n p a y m e n t s o r if yo u de fa u l t
. To p r ov i d e d efa u lt ra t e c a l c u l a t i on s, d i sc l o s u re s m a y b e m a d e t o gu a ra n ty a gen c i e s, t o fi nan c i a l a n d ed u c a t i o na l i n st i t u t i o n s, o r to st a t e a g en c i e s . To p rov i d e fi n an c i a l a id h i st o ry i n fo r m a t i o n , d i sc l o s u r e s m a y b e m a d e t o e d u c a t i o na l i n st i t u t i on s . To a ss i st p r og ra m a d mi n i str a t o rs w i t h tr a ck i n g r efun d s a n d c an c e l l a t i o n s, d i sc l o s u r e s ma y b e m a d e t o g u a ra n ty a g en c i e s, t o fi n an c i a l a n d e du ca t i o na l i n st i t u t i on s, o r t o fe de ra l o r st a t e ag en c i e s . To p r ov i d e a stan da r d i z e d m e tho d fo r e du ca t i o n a l i n st i t u t i o n s t o e ffi c i en t ly s ub mit stu d e n t e n r o ll m ent st a t u s e s, d i sc l o s u r e s ma y b e m a d e t o g uar an ty a ge n c i e s o r t o fi n a n c i a l an d e du c a t i o n a l i n st i t u t i on s . To c o u n s e l yo u in re pa ym e n t effo rts, d i sc l o s u r e s m a y b e m a d e t o g u a ra n ty a g en c i e s, t o fi n an c i a l a n d e du ca t i o na l i n st i t u t i on s, o r t o fe de ra l, sta t e , o r l o c a l ag en c i e s . I n t h e e v en t of li t i ga t i o n , w e ma y s e n d r e co r d s t o th e D e p a rt m e n t of J u st i c e , a c ou rt, adj u d i c a t i ve bo d y, c oun se l, pa rty, o r w i tn e s s if t h e d i sc l o s u r e is r e l eva n t a n d n e c e ss a ry t o t he li t i ga t i on . I f t h is i n fo r m a t i on , e i t he r a l o n e o r w i t h ot he r i n fo r m a t i on , i nd i c a te s a p ote n t i a l v i o l a t i o n of l a w, we m a y se n d it t o th e a p p ro p r i a t e au t ho r i ty fo r a ct i on . We ma y s end i n fo r m a t i o n t o m e m be rs of Co n g r e s s if yo u a s k t h e m t o h e lp yo u w i t h fe d e r a l st u de n t a id q u e st i on s . I n c i rc um st an c e s i n vo l v i n g e m p l oy m en t co mp l a i n ts, g r i e va n ce s, o r d i sc i p li na ry a ct i on s, w e ma y d i sc l o s e r e l e va n t r e c o r d s t o adj ud i c a te o r i n v e st i g a t e th e i ss ue s . I f p r ov i d e d fo r by a c o ll e ct i v e b a rg a i n i n g a g re e m e n t, we ma y d i sc l o s e r e co r d s t o a l ab o r o rg an i z a t i on r e c o g n i ze d u n d e r 5 U
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. 0 ho u rs ( 6 0 m i nu te s ) pe r r e spo n s e , i n c l u d i n g t h e t i m e fo r r ev i ew i ng i n str u ct i on s, s ea rc h i n g e x i st i n g da ta r e sourc e s, ga t he r i n g a n d m a i n ta i n i n g th e d a t a n e e d e d , a n d co mp l e t i n g a n d rev i ew i n g th e i n fo r m a t i o n co ll e ct i on . The obligation to r e s p o n d t o t h is c o ll e ct i o n is required t o obta in a b e nefit in a cc o r d a n c e w i t h 3 4 C F R 6 82
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