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 company/organization? 

2. Does the company/organization have another name such as a trade name or a 

 d/b/a name, under which the company 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 institutions? Click here to enter a date.

4. What name does the company/organization utilize to file its required annual compliance audit?

 

 

5. What is the company’s/organization’s fiscal year 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 company/organization? 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 owner:

 Name: 

 Job Title: 

 Business Street Address: Suite/Apt: 

 City: 

 State and Zip: 

 Telephone 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/XXXX
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.

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: 

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

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

 E-Mail Address: 

10. Does this company/organization have a web site (or home page) on the 

 Internet?

 If yes, list the electronic address (URL): 

 Yes No

11. Whom should we contact at this company/organization should we have questions regarding information on

 this 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 physical location (mailing address, 

 processing center, etc.) and provide the primary contact person, address, and phone number for each 

 location occupied. 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:

 Name: (primary contact person, include specific prefix, such as Mr., Ms., Dr.) 

 Street Address: Suite/Apt: 

 City: 

 State and Zip: 

 Purpose 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. Identify 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 Affiliated Organization

 Private, Not For Profit Organization

14. Check here if this company/organization owns or is owned by an eligible institution of Higher 

 Education (regardless of percentage) and provide the name of the entity, primary contact person, 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:

 Institution/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: 

15. Check here if this company/organization owns or is owned by another company/organization 

 (regardless of percentage) and provide the name of the entity, primary contact person, 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:

 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: 

16. Please indicate the Title IV, HEA services this company/organization performs on behalf of its clients:

 Process student financial aid applications, including FAFSA or Pre-FAFSA completion services 

 performed 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, by mail, or electronically

 Federal Perkins Loan 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 Loan, FFEL, and/or Perkins Loan

 programs, including cohort default analysis, enhanced loan counseling, delinquency assistance, 

 development/implementation 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 FISAP 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: 

17. Provide the names and OPE ID numbers for each client for who this company/organization contracts with 

 to perform any aspect of the institution’s participation under the Title IV, HEA programs. 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 client:

OPE ID Name of College, University, Institution of 

Higher Education

Service Start Date Service End Date
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.

OPE ID Name of College, University, Institution of 

Higher Education

Service Start Date Service End Date
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.

I hereby certify that, to the best of my knowledge and belief, all information in this document is true and

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 institution 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 

more than $25,000 or imprisonment of not more than five years, or both, for misinformation that is 

material 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. Department 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 such 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 maintaining 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 Servicer Oversight Group directly at (816) 268-0543 or fsapc3rdpartyserviceroversight@ed.gov
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.

Additional space for questions:

7. 

12. 

14. 

15. 

17.

OPE ID Name of College, University, Institution of 

Higher Education

Service Start Date Service End Date

Other: