### Page 1

**APPLICATION FOR CONTRACT OF FEDERAL LOAN**

**INSURANCE** Department of Education Federal Student Aid 

### PAPERWORK REDUCTION ACT BURDEN **STATEMENT** According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information u nless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845 - 012 8 . Public reporting burden for this collection of information is estimated to average 30 minutes per response, including ti mefor 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 obtain or retain benefit (Ti tle VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriation Act, 2014 ). If you have comments 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, Washington, DC 20202 directly. [Note: Please do not return the completed form to this address.] You can use this form to apply to participate in the Health Education Assistance Loan (HEAL) Program. 

### IN **STRUCTIONS Item**  **1 b.**  Enter your six digit code number, which was assigned to you by the HEAL Program. If you have not previously been assigned a code number, leave this item blank. If your institution has branch offices, they are covered by the approval of the application unless those offices ma intain the ir own loan accounting systems. In those cases a separate application(s) is required. **Items 3**  **and 4.**  If your institution is an instrumentality of a State (State Loan Agency), you are not required to compl ete Items #3 and #4. **Item 5.** Enter the regulatory (Federal or State) agency . You mu st attach supporting documents to show that your institution is capable of complying with the HEAL Statute, regulations, and policy directives. In addition to other inform ation you may wish to submit, you mu st submit the following: 

###  If the applicant is a commercia l i nstitution, a co py of the latest Annual Report; 

###  If the applicant is a lender for other Federal/State programs, a copy of your latest Call Report showing the loan activities (delinquency/default rates, etc.); 

###  If the applicant is a State Agency, a copy of your latest State Agency reports submitted to the Department of Education showing loan activities (delinquency/default rates, etc.).



### CONTACT **INFORMATION** In the next column please provide the requested information of th e officials who will serve as the points of contact to receive the following. (You must report any directory changes occurring during the application period to the HEAL Program.) 

### CODE NUMBER  Quarterly Interest Rate Announcements: CONTACT NAME 

### :
___________________________ _ ____ ADDRESS:


### ____________________________________

___________________________________________ EM AI L ADDRESS


### ________________ _ ________________ TELEPHONE NO. 

### __(_______)___

____________________ FAX NO.


### ______ (_______)_

______________________  Q uarterly Reports on HEAL Loans O utstanding: CONTACT NAME 

### :________________________________ ADDRESS:


### ____________________________________

___________________________________________ EM A IL ADDRESS


### ________________ _ ________________ TELEPHONE NO. 

### __(_______)_______________________ FAX NO.


### ______ (_______)_

______________________  Policy and Procedure s Questions: CONTACT NAME 

### :________________________________ ADDRESS:


### _________________________ ___________

___________________________________________ EM AI L ADDRESS


### _____________________ _ ___________ TELEPHONE NO. 

### __(_______)_______________________ FAX NO.


### ______ (_______)_

______________________  Loan and Disbursement Processing: CONTACT NAME 

### :______

__________________________ ADDRESS:


### ____________________________________

___________________________________________ EM AI L ADDRESS


### ________________________ _ ________ TELEPHONE NO. 

### __(_______)_______________________ FAX NO.


### ______ (_______)_

__________________ ____  Claim s Questions: CONTACT NAME 

### :________________________________ ADDRESS:


### ____________________________________

___________________________________________ EM AI L ADDRESS


### _______________________________ _ _ TELEPHONE NO. 

### __(_______)_______________________ FAX NO.


### ______ (_______)_

______________________  Entity serving as your Loan Servicer: CONTACT NAME 

### :________________________________ COMPANY NAME 

### :________________________________ ADDRESS:


### ____________________________________

______________________________ _____________ EM AI L ADDRESS


### _________________ ________________ TELEPHONE NO.


### __ (

_______ )

_______________________ FAX NO.


### ______ (_______)_

______________________  Custom er Service Contact Number(_____)__________

HEAL - 504

### Page 2 DEPARTMENT OF EDUCATION FEDERAL STUDENT AID 

### APPLICATION FOR CONTRACT **OF FEDERAL LOAN INSURANCE (A** **uthority : 42 U.S.C. 292**  **- 292o)**  

### FORM Under Review 60 day notice OMB NO. 1845 - 012 8 EXP. DATE XX/XX/20 XX DATE OF APPLICATION PLEASE FORW ARD ONE EXECUTED APPLICATION AND REQUIRED ATTACHME NTS TO: **DEPA RTMENT OF**  **EDUCA TION**  **Health Education A**

**ssistan ce**  **Loan (HEA L) Program**  **830 First Street NE Room 44 B4**  **Washington, DC 20202 -** **5454** 

### Wehereby apply for a contract under the provisions of Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 292 - 292o) and the Consolidated Appropriations Act, 2014 and the regulations of the Secretary issued there under. Wesubmit this application for the period _______________________________________to______________________________________ and t he attached information, incorporated in and made a part hereof (see instructions). 1a. NAME (Exact corporate title) AND ADDRESS (Street, City, State and Zip Code) 1 b. CODE NUMBER **CODE NUMBER** 2. TYPE OF INSTITUTION (Check applicable box) 

###  N ATIONAL BANK  STATE SAVINGS AND LOAN  INSURANCE COMPANY  STATE BANK (Member FDIC)  FEDERAL CREDIT UNION  PENSION FUND  STATE BANK (Nonmember FDIC)  STATE CREDIT UNION  SCHOOL LENDER  FEDERAL SAVINGS AND LOAN  MUTUAL SAVINGS BANK  OTHER (Specify)

_______ ________________

_ ITEMS 3 and 4 TO BE COMPLETED BY ALL APPLICANTS EXCEPT FOR ACADEMIC INSTITUTIONS OR STATE LOAN AGENCIES. 3. DATE ORGANIZED 4. INCORPORATED UNDER LAWS OF 5. W E ARE SUBJECT TO (Check applicable box)  FEDERAL SUPERVISION  STAT E SUPERVISION  OTHER BY: I agree to develop and follow written procedures for servicing and collection of HEAL loans . Although HEAL Policy 2004 - 1 no longer requires biennial audit be conducted as specified in Section 60.42(d ), we strongly encourage you to conduct such an audit . I also agree to incorporate any of our servicing and collection procedures used for our other loans of comparable dollar value that are more stringent than those required by Sections 60.34 of the HEAL regulations. In addition, I certify that neither this institution, nor any of its principals are debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency Sub - awardees (e.g., other corporations, partnerships, or other legal entities) have also provided the same certification to this institution. SIGNATURE OF OFFICER TYPED NAME AND TITLE OF OFFICER DATE **WA RNING: A** **ny**

**persons who knowingly makes a false statement or misrepresentation in a**  **HE AL transaction, bribes, or attempts to bribe a**  **Federal official, fraudulently obtains a HEA** **L Loan or comments any other illegal action in connection with a HEA** **L loan is sub ject to a fine or**  **imprisonment under Federal statute. FOR GOVERNMENT USE ONLY**   APPROVED  DISAPPROVED HEAL - 504