Fillable Form Approved: LOAN DISCHARGE APPLICATION: UNPAID REFUND (U.S. Department of Education)

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Form Approved: LOAN DISCHARGE APPLICATION: UNPAID REFUND (U.S. Department of Education)

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Page 1 of 4
LOAN DISCHARGE APPLICATION: UNPAID REFUND
William D. Ford Federal Direct Loan (Direct Loan) Program
Federal Family Education Loan (FFEL) Program
OMB No. 1845-0058
Form Approved
Exp. Date 08/31/2017
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any
accompanying document is subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal
Code and 20 U.S.C. 1097.
SECTION 1: BORROWER IDENTIFICATION
SECTION 2: SCHOOL AND LOAN INFORMATION
6. Are you (or, for a parent PLUS borrower, the
student) still attending this school?
Yes – You are not eligible for this discharge.
No – Continue to Item 8.
7.
Is this school still open?
Yes – Contact the school to attempt to resolve
the issue before applying. Skip to Item 9.
No – Continue to Item 8.
8. If this school is closed, were you (or, for parent
PLUS borrowers, was the student) attending the
school when it closed?
Yes – You may be eligible for a closed school
discharge. If you are unsure about which type
of loan discharge is most appropriate for you,
contact your loan holder. Continue to Item 9.
No – Continue to Item 9.
9. Do you have any other pending or approved
application(s) for discharge of a loan you obtained
to attend this school?
Yes – Skip to Item 11.
No – Continue to Item 10.
10. Has this school or any third party (see Section 6)
made, or is the school/third party considering you
for, a refund or payment for any loan for which
you are requesting a discharge?
Yes – Continue to Item 11.
No – Skip to Section 3.
For items 11–13, attach additional pages if you need
to report additional discharges, refunds, or payments.
11. Reason for discharge, refund, or payment:
12. Provide the following about the person or
organization from whom you received the
discharge, refund, or payment:
a. Name:
b. Telephone Number:
13. Amount you received or that you expect to
receive: $
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
City, State, Zip Code
Telephone – Primary
Telephone – Alternate
E-mail (optional)
1. You are applying for this loan discharge as a:
Student borrower – Skip to Item 4.
Parent borrower – Continue to Item 2.
2. Student Name (Last, First, MI):
3. Student SSN:
4. School Name:
5. School Address (street, city, state, zip code):
- -
- -
Page 2 of 4
SECTION 3: REFUND INFORMATION
If you are unable to provide any of the requested information, write “Don’t Know”. Attach a copy of any
documentation that supports your responses to Items 16 through 20. Examples of documentation may include, but are
not limited to, the school’s catalog, refund policy, tuition bill(s), enrollment contract, student account statement,
registration forms, withdrawal forms, attendance records, and any correspondence from the school that contains
information about the refund you believe the school owes you.
14. Do you have documentation from the school
showing the amount of the unpaid refund?
Yes – Attach the documentation and continue
to Item 15.
No – Skip to Item 16.
15. Do you believe that the amount of the refund
shown in the documentation is correct?
Yes – Sign and date the form in Section 4.
Submit the form and documentation to the
loan holder in Section 8.
No – Continue to Item 16.
Don’t Know – Continue to Item 16.
16. What amount do you believe the school owes
you? $
17. Why do you believe the school owes you this
amount?
18. Your (or, for parent PLUS borrowers, the
student’s) first and last dates of attendance at the
school:
OR Never Attended
OR Don’t Know
19. Your (or, for parent PLUS borrowers, the
student’s) program of study at the school:
20. If your (or, for parent PLUS borrowers, the
student’s) last date of enrollment was on or after
October 7, 2000, enter the total amount of the
federal grants and loans received for any part of
the period of enrollment for which the loan was
intended. $
Sign and date the form in Section 4. Submit the form
and documentation to the loan holder in Section 8.
Note: If your (or, for parent PLUS borrowers, the student’s) last date of enrollment was before October 7, 2000, contact
your loan holder for information about the documentation you must provide to request a discharge of your loan.
SECTION 4: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION
I certify that—
1.
I received the loan funds for which I am requesting a discharge directly, or they were applied as a credit to my
(or, for parent PLUS borrowers, the student’s) school account to pay the amount owed to the school.
2. I (or, for parent PLUS borrowers, the student) did not attend the school, withdrew, or was terminated from the
school within the time frame that would entitle me to a refund of some or all of my loan funds. Except as
provided in Section 2, Items 8 through 12, I have not received this refund, or any benefit of a refund to which I am
entitled, from the school or any third party.
3. I have read and agree to the terms and conditions for loan discharge, as specified in Section 7.
4.
Under penalty of perjury, all of the information I have provided on this application and in any accompanying
documentation is true and accurate to the best of my knowledge and belief.
I hereby assign and transfer to the U.S. Department of Education (the Department) any right to a refund on the
amount discharged that I may have received from the school identified in Section 2 of this form and/or any owners,
affiliates, or assignees of the school, and from any third party that may pay claims for a refund because of the actions
of the school, up to the amount discharged by the Department on my loan(s).
I authorize the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my
request or my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future
number that I provide for my cellular telephone or other wireless device using automated telephone dialing
equipment or artificial or prerecorded voice or text messages.
to
Date Borrower’s Signature
Borrower Name: Borrower SSN:
- -
Page 3 of 4
SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM
When completing this form, type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only
numbers. Example: February 10, 2014 = 02-10-2014. If you need more space to answer any of the items, continue on
separate sheets of paper and attach them to this form. Indicate the number of the Item(s) you are answering and
include your name and Social Security Number (SSN) on the top of page 2 and all attached pages. If a refund is owed for
more than one student or from more than one school, use separate forms for each student or school. Return the
completed form and any attachments to the address shown in Section 8.
SECTION 6: DEFINITIONS
The William D. Ford Federal Direct Loan (Direct Loan)
Program includes Federal Direct Stafford/Ford (Direct
Subsidized) Loans, Federal Direct Unsubsidized Stafford/
Ford (Direct Unsubsidized) Loans, Federal Direct PLUS
(Direct PLUS) Loans, and Federal Direct Consolidation
(Direct Consolidation) Loans.
The Federal Family Education Loan (FFEL) Program
includes Federal Stafford Loans (both subsidized and
unsubsidized), Federal Supplemental Loans for Students
(SLS), Federal PLUS Loans, and Federal Consolidation
Loans.
The holder of your Direct Loan Program loan(s) is the
Department. The holder of your FFEL Program loan(s)
may be a lender, a guaranty agency, or the Department.
Your loan holder may use a servicer to handle billing
and other communications related to your loans.
References to “your loan holder” on this form mean
either your loan holder or your servicer.
Loan discharge due to an unpaid refund cancels your
obligation (and any endorser’s obligation, if applicable)
to repay the portion of your loan that should have been
refunded. Any accrued interest and other charges on the
amount of the unpaid refund will also be discharged, and
you will be reimbursed for any amount that you have
repaid that exceeds the remaining balance of the loan
after the discharge. For consolidation loans, only the
amount of the unpaid refund that was included in the
consolidation loan will be discharged. The loan holder
reports the discharge to all credit reporting agencies to
which the holder previously reported the status of the
loan and removes any adverse credit history previously
associated with the loan.
The student refers to the student for whom a parent
borrower obtained a Direct PLUS Loan or Federal PLUS
Loan.
Program of study means the instructional program
leading to a degree or certificate in which you (or, for
parent PLUS borrowers, the student) were enrolled.
Third party refers to any entity that may provide
reimbursement for a refund owed by the school, such as
a State or other entity offering a tuition recovery
program or a holder of a performance bond.
SECTION 7: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON UNPAID REFUND
You are only eligible for this form of discharge if you
received the loan on which you are requesting
discharge on or after January 1, 1986.
By signing this form, you are agreeing to provide, upon
request, testimony, a sworn statement, or other
documentation reasonably available to you that
demonstrates to the satisfaction of the Department or
its designee that you meet the qualifications for loan
discharge based on unpaid refund, or that supports any
representation that you made on this form or any
accompanying documents.
By signing this form, you are agreeing to cooperate with
the Department or the Department’s designee in any
enforcement action related to this form.
This application may be denied, or you discharge may be
revoked, if you fail to provide testimony, a sworn
statement, or documentation upon request, or if you
provide testimony, a sworn statement, or documentation
that does not support the material representation that
you have made on this form or on any accompanying
documents.
SECTION 8: WHERE TO SEND THE COMPLETED FORM
If you need help completing this form, call:
(If no telephone number is shown, call your loan holder.)
Return the completed form and any documentation to:
(If no address is shown, return to your loan holder.)
Page 4 of 4
SECTION 9: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 552a)
requires that the following notice be provided to you:
The authorities for collecting the requested information
from and about you are §421 et seq. and §451 et seq. of
the Higher Education Act of 1965, as amended (20 U.S.C.
1071 et seq. and 20 U.S.C. 1087a et seq.) and the
authorities for collecting and using your Social Security
Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20
U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b).
Participating in the William D. Ford Federal Direct Loan
(Direct Loan) Program or the Federal Family Education
Loan (FFEL) Program and giving us your SSN are voluntary,
but you must provide the requested information,
including your SSN, to participate.
The principal purposes for collecting the information on
this form, including your SSN, are to verify your identity,
to determine your eligibility to receive a loan or a benefit
on a loan (such as a deferment, forbearance, discharge, or
forgiveness) under the Direct Loan and/or FFEL Programs,
to permit the servicing of your loan(s), and, if it becomes
necessary, to locate you and to collect and report on your
loan(s) if your loan(s) becomes delinquent or defaults. We
also use your SSN as an account identifier and to permit
you to access your account information electronically.
The information in your file may be disclosed, on a case-
by-case basis or under a computer matching program, to
third parties as authorized under routine uses in the
appropriate systems of records notices. The routine uses
of this information include, but are not limited to, its
disclosure to federal, state, or local agencies, to private
parties such as relatives, present and former employers,
business and personal associates, to consumer reporting
agencies, to financial and educational institutions, and to
guaranty agencies in order to verify your identity, to
determine your eligibility to receive a loan or a benefit on
a loan, to permit the servicing or collection of your loan(s),
to enforce the terms of the loan(s), to investigate possible
fraud and to verify compliance with federal student
financial aid program regulations, or to locate you if you
become delinquent in your loan payments or if you
default. To provide default rate calculations, disclosures
may be made to guaranty agencies, to financial and
educational institutions, or to state agencies. To provide
financial aid history information, disclosures may be made
to educational institutions. To assist program
administrators with tracking refunds and cancellations,
disclosures may be made to guaranty agencies, to financial
and educational institutions, or to federal or state
agencies. To provide a standardized method for
educational institutions to efficiently submit student
enrollment statuses, disclosures may be made to guaranty
agencies or to financial and educational institutions. To
counsel you in repayment efforts, disclosures may be
made to guaranty agencies, to financial and educational
institutions, or to federal, state, or local agencies.
In the event of litigation, we may send records to the
Department of Justice, a court, adjudicative body, counsel,
party, or witness if the disclosure is relevant and necessary
to the litigation. If this information, either alone or with
other information, indicates a potential violation of law,
we may send it to the appropriate authority for action. We
may send information to members of Congress if you ask
them to help you with federal student aid questions. In
circumstances involving employment complaints,
grievances, or disciplinary actions, we may disclose
relevant records to adjudicate or investigate the issues. If
provided for by a collective bargaining agreement, we may
disclose records to a labor organization recognized under
5 U.S.C. Chapter 71. Disclosures may be made to our
contractors for the purpose of performing any
programmatic function that requires disclosure of records.
Before making any such disclosure, we will require the
contractor to maintain Privacy Act safeguards. Disclosures
may also be made to qualified researchers under Privacy
Act safeguards.
Paperwork Reduction Notice. 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
1845-0058. 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 a benefit (34
CFR 682.402(l)(4), or 685.216(c)). If you have comments
or concerns regarding the status of your individual
submission of this form, contact your loan holder(s) (see
Section 8) directly.
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Form Approved: LOAN DISCHARGE APPLICATION: UNPAID REFUND (U.S. Department of Education)

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Completed 15 June 2021

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