### 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 I D 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 Am ount Guaranteed Am

ount Disbursed Prom

issory 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 

# □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ HEAL

— 510 PAGE 1 FORM APPROVED: OMB NO 1845

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— 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

- Judgm ent 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 ED Date ED Approval Date
**10. Death** 

### Notified of Death Date Official Notification of Death Received Date
**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 to the 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 be returned to the borrower. FOR PSC USE ONLY

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