This space for lender use only
OMB No. 1845-0101
Exp. Date 8/31/2022
Important: Pursuant to Section 155 of the Higher Education Act of 1965, as amended, (HEA) and to satisfy the requirements of Section 128(e)(3) of the Truth in
Lending Act, a lender must obtain a self-certification signed by the applicant before disbursing a private education loan. The school is required on request to provide
this form or the required information only for students admitted or enrolled at the school. Throughout this Applicant Self-Certification, “you” and “your” refer to the
applicant who is applying for the loan. The applicant and the student may be the same person.
Instructions: Before signing, carefully read the entire form, including the definitions and other information on the following page. Submit the signed form
to your lender.
SECTION 1: NOTICES TO APPLICANT
Free or lower-cost Title IV federal, state, or school student financial aid may be available in place of, or in addition to, a private
education loan. To apply for Title IV federal grants, loans and work-study, submit a Free Application for Federal Student Aid
(FAFSA) available at www.fafsa.ed.gov, or by calling 1-800-4-FED-AID, or from the school’s financial aid office.
A private education loan may reduce eligibility for free or lower-cost federal, state, or school student financial aid.
You are strongly encouraged to pursue the availability of free or lower-cost financial aid with the school’s financial aid office.
The financial information required to complete this form can be obtained from the school’s financial aid office. If the lender has
provided this information, you should contact your school’s financial aid office to verify this information and to discuss your
SECTION 2: COST OF ATTENDANCE AND ESTIMATED FINANCIAL ASSISTANCE
If information is not already entered below, obtain the needed information from the school’s financial aid office and enter it on the appropriate line. Sign
and date where indicated. See Section 5 for definitions of financial aid terms.
Student’s cost of attendance for the period of enrollment covered by the loan
Estimated financial assistance for the period of enrollment covered by the loan
Difference between amounts A and B
WARNING: If you borrow more than the amount on line C, you risk reducing your eligibility for
free or lower-cost federal, state, or school financial aid.
SECTION 3: APPLICANT INFORMATION
Enter or correct the information below.
Full Name and Address of School ________________________________________________________________________________________________________
Applicant Name (last, first, MI) ___________________________________________________ Date of Birth (mm/dd/yyyy) _____/_____/__________
Permanent Street Address __________________________________________________________________
City, State, Zip Code __________________________________________________________________ ____________________
Area Code / Telephone Number Home ( ) ____________________________ Other ( ) ____________________________
Period of Enrollment Covered by the Loan (mm/dd/yyyy) From _____ / _____ / _______ to _____ / _____ / _______
If the student is not the applicant, provide the student’s name and date of birth.
Student Name (last, first, MI) ____________________________________________________ Student Date of Birth (mm/dd/yyyy) _____/_____/__________
SECTION 4: APPLICANT SIGNATURE
I certify that I have read and understood the notices in Section 1 and, that to the best of my knowledge, the information provided on this form is true and correct.
Signature of Applicant ____________________________________________________________________ Date (mm/dd/yyyy) _______________________