For purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. 

### Third Party Servicer Data Form 1. What is the legal name of this compan y/ organization?
2. Does the compan y/ organization have another name such as a trade name or a d/b/a name, under which the compan y conducts business?
If yes, please provide the names(s): Yes No

3. When did the company/organization begin conducting business as a third party servicer on behalf of Title IV, HEA i nstitutions? Click here to enter a date.
4. What name does the company /organization utilize to file its required annual compli ance audit?

5. What is the company ’s/organization’s fiscal y ear end date? Click here to enter a date.
6. What is the company ’s/organization’s Dun & Bradstreet (DUNS) number? N/A
7. Who are the owner/owners of this compan y/ organization? If y ou need more space, please use additional space provide d on last page of form or attach an additional sheet and inclu de the following for each owner:
Name: Job Title: Business Street Address: Suite/Apt: City : State and Zip: Teleph one Number (including area code xxx - xxx - xxxx ): Fax Number (including area code xxx - xxx - xxxx ): E

- Mail Address: OMB # Form Approved Exp. Date: XX/XX/XXXXFor purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. 8. Who is completing this form?
Name : (include prefix, such as Mr., Ms., Dr.) Job Title: Telephone Number : (including area code xxx - xxx - xxxx ) E

- Mail Address:
9. Who is the highest ranking officer (CEO/COO/President) of this company /organization?
Name: Job Title: Business Street Address: Suite/Apt: City : State and Zip: Tele phone Number: (including area code xxx

- xxx - xxxx) Fax Number: (including area code xxx

- xxx - xxxx) E

- Mail Address:
10. Does this compan y/ organization have a web site (or home page) on the I ntern et? If yes, list the electronic address (URL): Yes No

11. Whom should we contact at this compan y/ organization should we have questions regarding information on t his form or need to respond to an institutional inquiry ? Name: (include prefix, such as Mr., Ms., Dr.) Job Title: Telephone Number: (including area code xxx - xxx - xxxx ) Fax Number: (including area code xxx - xxx - xxxx ) E

- Mail Address:
12. Check here if this company /organization maintains more than one phy sical location (mailing address, processing center, etc.) and provide the primary contact person, address, and phone number for each location occupied. If y ou need more space, please use additional space provided on last page of form or attach an additional sheet and include the following for each entit y: Name: (primary

contact person, include specific prefix, such as Mr., Ms., Dr.) Street Address: Suite/Apt: City : State and Zip: Pu rpose of Location: (mailing address, processing center, etc.)For purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. 13. I dentify

the ownership structure of this company /organization: For Profit Corporation

– Publicly

Traded Corporation

– Not Publicly Traded Partnership Sole Proprietorship
Not for Profit State Owned Organization State Affili ated Organization Private, Not For Profit Organization 14. Check here if this company /organization own s or is owned b y an eligible institution of Higher Education ( regardless of percentage ) and provide the name of the entity, primary c ontact per son, phone number and e

- mail below. If you need more space, please use additional space provided on last page of form or attach an additional sheet and include the following for each entity : In stitution /Organization Name: Name: (primary

contact’s name, include prefix, such as Mr., Ms., Dr.) Telephone Number: (including a rea code xxx - xxx - xxxx ) Fax Number: (including area code xxx - xxx - xxxx ) E

- Mail Addre ss: Description of Relationship with the entity listed above: 15. Check here if this compan y/ organization own s or is owned b y another compan y/ organization ( regardless of percentage ) and provide the name of the entity , primary c ontact person, phone n umber , and e

- mail below. If you need more space, please use additional space provided on last page of form or attach an additional sheet and includ e the following for each entity : Company /Corporation /Organization Name: Name: (primary

contact’s name, include prefix, such as Mr., Ms., Dr.) Telephone Number: (including area code xxx

- xxx - xxxx) Fax Number: (including area code xxx

- xxx - xxxx) E

- Mail Address: Description of Relationship with the entity listed above: 1 6 . Please indicate the Title I V, HEA services this compan y/ organization performs on behalf of its clients: Process student financial aid applications, including FAFSA or Pre

- FAFSA completion services perf ormed on behalf of an eligible institution Collect, review, and/or maintain supporting documentation required to process Title IV funds Determine student eligibility and related activities (R2T4, SAP, Verification, Professional Judgment, Dependency

Override, etc.) Award, certify , originate, and/or disburse Title IV funds Delivery of Title IV credit balance refunds to students or parents (via cash, check, ACH, debit card, or other means)For purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. Prepare and/or certify request for advance or reimbursement funding Fiscal reconciliation of Title IV, HEA program accounts Provide entrance and exit loan counseling, including in person, b y m ail, or electronically Federal Perkins Lo an servicing Federal Perkins Loan collections Financial aid counseling, including assistance provided to students or parents in person, over the phone, or by any electronic means, including operation of call centers Perform default prevention management functions for Direct L oan, FFEL, and/or Perkins L oan programs, i ncluding cohort default anal ysis, enhanced loan counseling, delinquency assistance, development/imple mentation of a default management plan, and/or other default prevention outreach activities Preparation/dissemination of required consumer information disclosures, including general, campus crime, drug and alcohol prevention, graduation rates, placement rates and gainful employment disclosures Preparation and or submission of required reports including enrollment reporting to NSLDS, IPEDS, Campus Crime and Security , and FI SAP reporting Financial aid consulting, including financial aid staffing, interim management, processing support, and/or development and maintenance of written policies and procedures Other, please describe:

1 7 . Provide the names and OPE I D numbers for each client for who this company /organization contracts with to perform an y aspect of the institution’s participation under the Title IV, HEA programs. If yo u need more space, please use additional space provided on last page of form or attach an additional sheet and include the following for each client:
OPE I D Name of College, University , I nstitution of

Higher Education Service Start Date Service End DateFor purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. OPE I D Name of College, University , I nstitution of

Higher Education Service Start Date Service End DateFor purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. **I hereby certify that, to the best of my knowledge and belief, all information in this document is true an d**  **correct. I understand that if my company/organization provides false or misleading information, the Department considers this to be a breach of the fiduciary standard of conduct and may terminate the**  **servicer’s eligibility to contract with any institutio n to administer any aspect of an institution’s**  **participation in the Title IV, HEA programs. I also understand that I may be subject to a fine of not mo**  **re than $25,000 or imprisonment of not more than five years, or both, for misinformation that is ma**  **teria l to receipt and stewardship of federal student financial aid funds.** 
**Signature of individual completing this form:**

**Date:** Click here to enter a date. **Signature of President/CEO/COO: (include prefix, such as Mr., Ms., Dr.)** 

**Date:** Click here to enter a date.
**Please attach a copy of this company’s organizational chart with employee names and titles of those**  **individuals who serve in a managerial or supervisory role and return this form to:** 

**Third Party Servicer Oversight Group U.S. Dep**  **artment of Education Kansas City School Participation Division**  **1010 Walnut Street; Suite 336 Kansas City, MO 64106**  **(816) 268**
**- 0543**  **fsapc3rdpartyserviceroversight@ed.gov**

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless su ch collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845

- XXXX

. Public reporting burden for this collection of information is estimated to average 75 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and ma intaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain the benefit to contract with eligible institutions pursuant to 34 C.F.R. § 668.25. If you have comments or concerns regarding the status of your individual submission of this form, please contact the Third Party Se rvicer Oversight Group directly at (816) 268

- 0543 or fsapc3rdpartyserviceroversight@ed.govFor purposes of this form, company/organization refers to an individual or a state, or a private, profit, or non

- profit organization that enters into a contract or agreement with an eligible institution to administer any aspect of the institution’s participation in the Title IV programs. **Additional space for questions:**
**7.**
**12.**

**14.**

**15.**

**17.**
OPE I D Name of College, University , I nstitution of

Higher Education Service Start Date Service End Date

**Other:**