Fill - Free fillable Loan Rehabilitation Incomeand Expense PDF form

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LOAN REHABILITATION: INCOME AND EXPENSE

INFORMATION

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family

Education Loan (FFEL) Program

OMB No. 1845-0120

Form Approved

Exp. Date 5/31/2020

Email (Optional)

Telephone - Alternate

Telephone - Primary

Zip Code

State

City

Address

Name

SSN

Check this box if any of your information has changed.

Please enter or correct the following information.

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 INFORMATION

SECTION 2: HOUSEHOLD INCOME AND REASONABLE AND NECESSARY MONTHLY EXPENSES

You received this form because you asked to rehabilitate your defaulted loans, but objected to the payment amount your

loan holder calculated using the 15% formula (see Section 6). After receiving this form, your loan holder will offer an

alternative payment amount. The alternative amount may be less or more than the amount calculated using the 15%

formula. To begin rehabilitating your defaulted loans, you must choose between the two amounts. To rehabilitate, you must

make 9 on-time payments of that amount over a period of 10 consecutive months.

Provide the monthly income and expense information listed below. Include documentation of these sources of income or

expenses if your loan holder asks you to. Include your spouse's income only if your spouse contributes to your household

income. Your loan holder has the authority to determine if the claimed amount of any expense is reasonable and necessary.

Before entering your monthly income and expenses, carefully read the entire form, including Sections 5, 6, and 7.

MONTHLY INCOME MONTHLY EXPENSES

Your employment income

Spouse's employment income

Child support received

Social Security benefits

Worker's compensation

Public assistance

List types

Other income

Describe

Total monthly income (sum

of items 1 through 7)

If your total monthly

income is $0, explain

your means of

support

10.

Food

11.

Housing

12.

Utilities

13.

Basic communication

14.

Necessary medical/dental

15.

Necessary insurance

16.

Transportation

Number of vehicles

17.

Child/dependent care

18.

Required child/spousal support

19.

Federal student loan payments

20.

Private student loan payments

21.

Other expenses

Describe

22.

Total monthly expenses (sum

of items 10 through 21)

Page 1 of 5

Continue to Sections 3 and 4 on page 2.

Borrower SSNBorrower Name

SECTION 3: FAMILY SIZE AND SPOUSE IDENTIFICATION

Your family size includes you, your spouse, and your children (including unborn children who will be born before the end of

the current calendar year), if the children will receive more than half of their support from you. Your family size includes other

people only if they live with you now, receive more than half of their support from you now, and will continue to receive this

support from you for the year for which you are certifying your family size. Support includes money, gifts, loans, housing,

food, clothes, car, medical and dental care, and payment of college costs.

23.

Family size

24.

Are you requesting rehabilitation of a Direct Consolidation Loan or a Federal Consolidation Loan that was made jointly to

you and your spouse?

Yes. Enter your spouse's name and SSN:

No. Continue to Section 4.

Spouse's Name

Spouse's SSN

SECTION 4: UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION

I understand that:

1. I have received this form because I requested the opportunity to rehabilitate my defaulted loans and objected to the

reasonable and affordable monthly payment amount calculated using the 15% formula.

2. My loan holder will calculate an alternative reasonable and affordable monthly payment amount that will be based

solely on the information I provide on this form and, if requested, supporting documentation.

3. If I do not accept either the 15% formula payment amount or the payment amount determined by my loan holder

based on information from this form, the loan rehabilitation process will not proceed and I will be required to repay my

defaulted loans in accordance with the terms of the loan and applicable law.

4. If I do not provide any supporting documentation requested by my loan holder by the deadline specified by my loan

holder, my request for loan rehabilitation will not be considered.

5. If I want to rehabilitate a defaulted Direct Consolidation Loan or Federal Consolidation Loan that was made jointly to

me and my spouse and am requesting an alternative payment amount, my spouse and I must each sign below.

6. If I rehabilitate a loan and default on the same loan again in the future, I may not rehabilitate that loan a second time.

7. I must notify my loan holder immediately if my address changes.

8. If my loan is rehabilitated, my loan will be sold or transferred to a new loan holder or loan servicer. After the sale or

transfer, I will be asked to select a repayment plan. If I do not select a repayment plan, my loans will be placed on the

standard repayment plan, which will likely require me to make a much higher monthly payment amount than the

payment I made to rehabilitate my loan.

9. After my loan is rehabilitated, I may be eligible to repay my loans under an income-driven repayment plan that bases

my payment on my income and family size. An income-driven repayment plan is the type of repayment plan most

likely to have a monthly payment similar to the payment I made to rehabilitate my loans.

10. I can learn more about the eligibility requirements and application process for income-driven repayment plans by

visiting StudentAid.gov/IDR or by asking my loan holder.

I certify that (1) the information that I have provided on this form is true and correct and (2) upon request, I will provide

additional documentation to my loan holder to support the information I have provided in this form.

I authorize the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my request

or my loans, including the repayment of my loans, at any number that I provide on this form or any future number that I

provide for my cellular telephone or other wireless device using automated dialing equipment or artificial or prerecorded

voice or text messages.

Borrower's Signature

Date

Spouse's Signature

Date

Your spouse must sign this form only if you entered your spouse's name and SSN in Section 3.

Page 2 of 5

SECTION 5: INSTRUCTIONS

If you are not completing this form electronically, type or

print using dark ink. Enter dates as month-day-year (mm-dd-

yyyy). Use only numbers. Example: March 14, 2017 =

03-14-2017. Include your name and the account numbers for

your defaulted loans on any documentation that you are

required to submit with this form. If you need help

completing this form, contact your loan holder.

Return the completed form to the address shown in

Section 8

MONTHLY INCOME IN SECTION 2 (ITEMS 1-9)

Your loan holder may request supporting documentation

for any income items.

Employment income documentation may include a pay

stub or a letter from the employer stating the income paid to

you by that employer.

Child support, Social Security benefits, worker’s

compensation, or public assistance documentation may

include copies of benefits checks or a benefits statement, a

letter from a court, a governmental body, or the individual

paying child support, specifying the amount of the benefit.

Public assistance: Identify the type of public assistance

received (see definition of “public assistance” in Section 6).

Other income: Include any other income not covered in

items 1-6 and identify the source of the income.

If you report that your Total Monthly Income is zero,

explain your means of support in Item 9.

MONTHLY EXPENSES IN SECTION 2 (ITEMS 10-22)

For each monthly expense, provide the amount you

usually spend each month. Your loan holder may request

supporting documentation for any of these items. Do not

include a single expense in more than one category. If you

have no expenses under a category, enter 0 for that

category.

Food: Include the amount spent on food, even if

purchased using the Supplemental Nutrition Assistance

Program (SNAP) (food stamps).

Housing: Include the amount spent on housing and

shelter, such as rent, required security deposits, mortgage

payments (including principal, interest, taxes, and

homeowner’s insurance), maintenance, and repairs.

Utilities: Include the amount spent on housing-related

utility bills, such as gas, electric, fuel oil, water, sewer, trash,

and recycling.

Basic communication: Include the amount spent on

basic communication expenses, such as basic telephone,

internet, and cable TV.

Medical and dental: Include the amount spent on

necessary medical and dental expenses and procedures not

covered by insurance, such as medically necessary

prescription and nonprescription medications, and

medically necessary nutritional supplements. Do not include

any costs relating to medical or dental insurance premium

payments.

Insurance: Include the amount spent on insurance, such

as necessary renter’s, auto, medical, dental, or life insurance.

Include any amounts paid toward insurance premiums.

However, if the income amount you listed under Monthly

Income already reflects deductions from your pay for

insurance premiums, do not list the amount of these

deductions as an Insurance expense. Include homeowner’s

insurance under Item 11 (Housing).

Transportation: Include the amount spent on basic

transportation expenses such as fuel, car payments, basic

vehicle maintenance, public transportation, tolls, and

parking. Also list the number of vehicles for which you are

claiming related transportation expenses.

Child/dependent care: Include the amount spent on

care for children or other dependents in the household and

other work-related child/dependent care expenses.

Legally required child /spousal support: Include the

amount spent on legally required child support and spousal

support.

Federal student loan payments: Include the total

monthly amount you pay on any federal student loans

except for the defaulted loans you are trying to rehabilitate,

unless you are subject to mandatory withholding such as

wage garnishment or Treasury offset (e.g., your Social

Security is being garnished). If you are subject to wage

garnishment or Treasury offset include the amount that is

collected from you each month.

Private student loan payments: Include the total

monthly amount you pay on any private student loans.

Include any type of payment, voluntary or otherwise.

Other expenses: Include the amount spent on any other

necessary expenses not covered in items 10 - 20 and explain

these expenses. These other expenses will be considered

only if the Department of Education determines that they

should be considered. If more space is needed to list other

expenses, attach a separate piece of paper and include your

name and Social Security Number at the top.

Page 3 of 5

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 PLUS Loans, Federal Consolidation

Loans, and Federal Supplemental Loans for Students (SLS).

Rehabilitation of your defaulted loan occurs only after

you have made 9 voluntary, reasonable and affordable

monthly payments within 20 days of the due date during 10

consecutive months and, for FFEL loans held by a guaranty

agency, when the loan has been sold to an eligible lender or

assigned to the U.S. Department of Education (the

Department). When you rehabilitate your loans, you will

regain all the benefits of the Direct Loan Program or FFEL

Program, including eligibility for deferments or forbearances

and for a repayment plan with a monthly payment amount

based on your income. You will also regain eligibility to

receive additional federal student aid, including additional

federal student loans. After a defaulted loan is rehabilitated,

your loan holder will instruct any consumer reporting

agency (credit bureau) to which the default was reported to

remove the default from your credit history.

Reasonable and affordable payment amount means a

monthly payment determined by the loan holder based

either on the 15% formula or on information provided in this

form and supporting documentation. It cannot be a

percentage of your total loan balance or based on

information unrelated to your total financial circumstances.

The 15% formula means 15% of the amount by which

your Adjusted Gross Income exceeds 150% of the poverty

guideline amount that is applicable to your family size and

state, divided by 12. Your minimum payment may not be

less than $5.00.

The loan holder of a defaulted Direct Loan Program

loan is the Department. The loan holder of a defaulted FFEL

Program loan may be a guaranty agency or the Department.

Public assistance means payments you receive under a

federal or state program. These assistance programs include,

but are not limited to, Temporary Assistance for Needy

Families (TANF), Supplemental Security Income (SSI), Food

Stamps/Supplemental Nutritional Assistance Program

(SNAP), or state general public assistance.

SECTION 7: LOAN REHABILITATION AGREEMENT

To rehabilitate your loan, you must accept either the

monthly rehabilitation payment amount determined using

the 15% formula, or the payment amount determined based

on the monthly income, monthly expenses, and family size

information that you provide on this form and on any

requested supporting documentation.

Your loan holder will provide you with a written loan

rehabilitation agreement confirming your monthly

rehabilitation payment amount.

To accept the loan rehabilitation agreement, you must

sign the agreement and return it to your loan holder.

During the loan rehabilitation period, the loan holder

will limit contact with you on the loan being rehabilitated to

collection activities that are required by law or regulation,

and to communication that supports the rehabilitation.

If you do not accept either monthly payment amount,

your rehabilitation request will not be considered any

further.

SECTION 8: WHERE TO SEND THE COMPLETED FORM

Return the completed form and any documentation to:

(If no address is shown, return to your loan holder.)

If you need help completing this form, call:

(If no telephone number is shown, call your loan holder.)

Page 4 of 5

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 loans, and, if

it becomes necessary, to locate you and to collect and

report on your loans if your loans become delinquent or

default. 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 loans, to enforce the

terms of the loans, 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

1845-0120. Public reporting burden for this collection of

information is estimated to average 60 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 a benefit in accordance with

34 CFR 682.405 or 685.211. If you have questions regarding

the status of your individual submission of this form, contact

your loan holder (see Section 8).

Page 5 of 5

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