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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 unless such collection 

displays a valid OMB control number. The valid OMB control number 

for this information collection is 1845-0128. Public reporting burden for 

this collection of information is estimated to average 30 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 obtain or retain benefit (Title 

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.

INSTRUCTIONS

Item 1b. 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 

maintain their 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 complete Items #3 and #4.

Item 5. Enter the regulatory (Federal or State) agency.

You must attach supporting documents to show that your institution is 

capable of complying with the HEAL Statute, regulations, and policy 

directives. In addition to other information you may wish to submit, you 

must submit the following:

If the applicant is a commercial institution, a copy 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 the 

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:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______ (_______)_______________________

Quarterly Reports on HEAL Loans Outstanding:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______ (_______)_______________________

Policy and Procedures Questions:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______ (_______)_______________________

Loan and Disbursement Processing:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______ (_______)_______________________

Claims Questions:

CONTACT NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______ (_______)_______________________

Entity serving as your Loan Servicer:

CONTACT NAME:________________________________

COMPANY NAME:________________________________

ADDRESS:____________________________________

___________________________________________

EMAIL ADDRESS_________________________________

TELEPHONE NO.__(_______)_______________________

FAX NO. ______ (_______)_______________________

Customer Service Contact Number(_____)__________

HEAL-504
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DEPARTMENT OF EDUCATION

FEDERAL STUDENT AID

APPLICATION FOR CONTRACT

OF FEDERAL LOAN INSURANCE

(Authority: 42 U.S.C. 292-292o)

FORM Under Review 60 day notice

OMB NO. 1845-0128

EXP. DATE XX/XX/20XX

DATE OF APPLICATION

PLEASE FORWARD ONE EXECUTED APPLICATION AND REQUIRED ATTACHMENTS TO:

DEPARTMENT OF EDUCATION

Health Education Assistance Loan (HEAL) Program

830 First Street NE Room 44B4

Washington, DC 20202-5454

We hereby 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. We submit this application for 

the period

_______________________________________to______________________________________

and the 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)

 NATIONAL 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. WE ARE SUBJECT TO (Check applicable box)

 FEDERAL SUPERVISION  STATE 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

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

Federal official, fraudulently obtains a HEAL Loan or comments any other illegal action in connection with a HEAL loan is subject to a fine or 

imprisonment under Federal statute.

FOR GOVERNMENT USE ONLY

 APPROVED

 DISAPPROVED

HEAL-504