LENDER'S APPLICATION FOR INSURANCE CLAIM ON A FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) 

WARNING: Any person who knowingly makes a false statement or misrepresentation in a HEAL loan transaction, bribes or attempts to 

bribe a Federal official, fraudulently obtains a HEAL loan, or commits any other illegal action in connection with a HEAL loan

 is subject to possible fine and imprisonment under Federal Statue.

1a. Holder Information 1b. Servicer Information

Holder ID Number:______________________________________________

Holder Name:__________________________________________________

Address:______________________________________________________

City/State/Zip Code:__________________________________________

Telephone No.:___________________ Fax:_________________________

Servicer ID Number:________________________________________________

Servicer Name:____________________________________________________

Address:__________________________________________________________

City/State/Zip Code:________________________________________________

Telephone No.:____________________ Fax:_____________________

Original Claim Submission

Yes □ No □

If no, date on letter rejecting original claim submission: 

1c. Claim Type

Judgment

□

Bankruptcy Chapter 11

□

Bankruptcy Chapter 13

□

Bankruptcy Adversary

□

Skip

□

Unable to Serve

□

Disability

□

Death

□

Low Loan 

 □

Low Balance

□

2. Borrower Information

Borrower Name (Last, First , M.I.) Social Security No. Last Known Address City State Or Country Zip Code

3. Heal Loan Information and Documentation(Complete all columns for each loan listed.)

Loan ID Number Original Loan 

Amount 

Guaranteed

Amount

Disbursed

Promissory Note 

(Check one 

column)

Application 

(Check one 

column)

Repayment 

Schedule

Payment 

History 

(Check for 

Yes)

Principal & 

Interest 

Worksheet 

(Check for Yes)

No. of Months 

in Deferment

No. of Months in 

Forbearance

Original Copy with 

Affidavit

Original Copy Copy Affidavit

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HEAL — 510 PAGE 1 

FORM APPROVED:

OMB NO1845-0127
HEAL — 510 PAGE 2 

Borrower Name (Last, First, M.I.) Social Security No.

4.Claim Information

Borrower School Separation Date Repayment Begin Date Refinanced Loan?

Yes □ No □

Most Recent Delinquency Date Reported Credit Bureau Date

Due Diligence Letter 1 Date Due Diligence Letter 2 Date Due Diligence Letter 3 Date Due Diligence Letter 4 Date Prior Bankruptcy?

Yes □ No □

PCA 90 Day Letter Date PCA 120 Day Letter Date PCA 150 Day Letter Date Final Demand Date

5. Judgment Claim

Litigation Began Date Litigation ID Number Judgment Date Judgment Assignment Date Exemplified or Certified 

Judgment Received Date

Post-Judgment Interest Rate 

(Percent Only)

Continuing Interest 

Clause?

Yes □ No □

6. Bankruptcy Claim (All Bankruptcy claims must be filed within 10 days of notification and include required documentation.)

Official Notification of Bankruptcy 

Date

First Meeting of Creditors Included?

Yes □ No □

Proof of Claim Included?

Yes □ No □

Transfer of Proof of Claim?

Yes □ No □

Copy of Bankruptcy Plan Included?

Yes □ No □

Adversary Only Basis for Objection Included?

Yes □ No □

Copy of Complaint?

Yes □ No □

Complaint Date Copy of Summons?

Yes □ No □

Adversary Received Date

7. Skip 8. Unable to Serve

Skip Tracing Began 

Date

Determination

Date

No. of Attempts to 

Serve

Was Service Attempted by Officers of the Court

(Public Service)? Yes □ No □

Return of Service?

Yes □ No □

Last Attempt Date Copy of Complaint Included?

Yes □ No □

9. Disability

Notified of Disability Date Package Sent to EDDate EDApproval Date

10. Death

Notified of Death Date Official Notification of Death ReceivedDate

11. Low Loan 12. Low Balance 

All Loans Made Prior to 11/14/88 <$5000?

Yes □ No □

All Loans Made on After 11/4/88 <$2500?

Yes □ No □

Claim Amount <$1000?

Yes □ No □

13. Total Amount of Insurance Claim (Principal and Interest): $__________________________

I certify that the information on this form is correct. I have used standard commercial collection practices and conformed tothe due diligence standards of the HEAL 

regulations and policy guidelines. The borrower is not entitled to the deferment of principal, as provided in the Promissory Note(s). Any further payments by the 

borrower will bereturned to the borrower.

FOR PSCUSE ONLY

14a. Signature of Authorizing Official 14b. Name and Title (Please Print) 14c. Date