U.S. DEPARTMENT OF EDUCATION Federal Student Aid OMB Control Number 1845

- 0127 FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM (42 U.S.C. 292

- 2920) and the Consolidation Appropriations Act, 2014 

### LENDER’S APPLICATION FOR INSURANCE CLAIM PRA Burden Statement: A ccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of informati on unless such collection displays a valid OMB control number. T he valid OM B control number for this information collection is 184 5
- 0127

. P ublic 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. T he obligation to respond to this collection is required to obtain or retain benefit (Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriations Act, 2014). I f you have comment or concerns regarding the status of your individual submission of this form, please contact the HEAL Program, U.S. Department of Education 830 First Street NE, W ashington, DC 20202 directly. [Note: Please do not return the completed fo rm to this address.] 

### General Information : The amount of Federal insurance payment receiv ed depends upon whether there is compliance with HEAL statue, regulations, and policies, including those concerned with the making, servicing, and collection of the loan (s) and the timely submission of documents

. (See Secti on 60.13 and 60.38 through 60.41. ) T he following documents will assist you in completing this form: (1) HEAL Statute and Regulations; (2) Copy of borrow er’s application(s); (3) Or iginal Promissory N ote (s); (4) Copy of disbursement check (s); (5) Copy of borrow er’s deferment request(s); (6) Evidence of student enrollment status and date of separation; (7) Repayment schedule (s); (8) Copy of borrower’s forbearance request (s); (9) Litigation, bankruptcy, death, or disability documents; and (10) Payment and servicing history of borrow er’s account. 

### Instructions for completing the form : **Item 1a**  **.** Holder (owner) of the HEAL l oans. Provide six

- digit holder identification number, institution’s name, address, city, state, zip code, telephone number (including area code) , and fax number. **Item 1b**  **.** Servicer may be the same organizatio n as the holder or a different organization. This is where the loans are being serviced. Provide six

- digit holder identification number, institution’s name, address, city, state, zip code, telephone number (including area code) , and fax num ber. **Item 1c**  **.** Claim T ype. Place an “X” in the appropr iate box that reflects the type of claim submitted. **Item 2**  **.** Provide borrower’s nam e (if name has changed enter former name in p arentheses), social security number, last known address, including city, state , name of foreign country borrower reside (if ap plicable) and zip code. **Item 3**  **.** Provide 12

- digit HEAL Loan ID Number for each loan included in the claim, original loan and disbursed amount. For each loan ID number listed , the holder must check appropriate columns as to documents included in the claim package under promissory note, application, repayment schedule, payment history, principal/interest calculation worksheet, and the number of months in deferment and forbearance. **Item 4** 
. Claim Information. Complete all information requested regarding dates, and signify yes or no answers by placing an “X” in the appropriate box. NOTE: Go to Item 5, 6, 7, 8, 9, 10, 11, or 12 according to claim type selected. Item 5
. Jud gm ent Claim Fill in the information requested or check yes or no. Item 6
. Bankruptcy Claim Fill in all information requested or check yes or no. Item 7
. Skip Claim Fill in all information requested or check yes or no. Item 8. Unable to Serve Claim Fill in all information requested or check yes or no. Item 9. Disab ility Claim Fill in all information requested or check yes or no. Item 10. Death Claim Fill in all information requested or check yes or no. Item 11. Low Loan Amount Claim Check yes or no. Item 12. Low Balance Cla im Check yes or no. Item 13. Enter the total amount of principal and interest for all loans claimed. Item s 14a
. , 14b

. , and 14c. Self

- explanatory The following must be completed before submitting the form:

 Assigned promissory note(s) to the United States Government  Certified copy of the judgment and original assignment of the judgment to the United States Government  A signed claim form with support ing documentation **Send o riginal and**  **one copy of this form**  **and all other documentation to:** Health Education Assistance Loan (HEAL) Program Program Support Center (PSC) 12501 Ardennes Ave., Suite 100 Rockville, MD 20857