Consent to Obtain Credit Report
I consent to the U.S. Department of Education and its agents obtaining a report of my credit record and using the information from that
report in determining whether to make a Direct PLUS Loan to me. I understand that I will be notified in writing of the results of the
credit check with respect to my loan application.
Date of Birth (MM/DD/YYYY)
Privacy Act Disclosure Notice
The Privacy Act of 1974 (5 U.S.C.552a) requires that the following notice be provided to you. The authority for collecting the information requested on this form is §451 et seq. of the Higher
Education Act of 1965, as amended. Your disclosure of this information is voluntary. However, if you do not provide this information, you cannot be considered for a Direct PLUS Loan. The
information on this form will be used to determine your eligibility for a Direct PLUS Loan. The information in your file may be disclosed to third parties as authorized under routine uses in the
Privacy Act notices called “Title IV Program Files” (originally published on April 12, 1994, Federal Register, Vol. 59 p. 17351) and “National Student Loan Data System” (originally published
on December 20, 1994, Federal Register, Vol. 59 p. 65532). Thus, this information may be disclosed to Federal and state agencies, private parties such as relatives, present and former
employers and creditors, and contractors of the Department of Education for purposes of administration of the student financial assistance program, for enforcement purposes, for litigation
where such disclosure is compatible with the purposes for which the records were collected, for used by Federal, state, local, or foreign agencies in connection with employment matters or the
issuance of a license, grant, or other benefit, for use in any employee grievance or discipline proceeding in which the Federal Government is a party, for use in connection with audits or other
investigations, for research purposes, for purposes of determining whether particular records are required to be disclosed under the Freedom of Information Act, and to a Member of Congress in
response to an inquiry from the congressional office made at your written request.
Because we request your social security number (SSN), we must inform you that we collect your SSN on a voluntary basis, but section 484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) provides
that, in order to receive any grant, loan, or work assistance under Title IV of the HEA, a student must provide his or her SSN. Your SSN is used to verify your identity, and as an account
number (identifier) throughout the life of your loan(s) so that data may be recorded accurately.
PLUS Refund Authorization
Normally, if all charges on the student’s account are paid in full, the refund check from any PLUS proceeds will be mailed to the
parent borrower. If you indicated on the front page of this application that you would like any refund from this PLUS Loan to be issued
to your student, please complete the information in the box below.
In order for the student to receive this refund, we will need the following information
completed by the parent requesting the loan:
Student’s ID or Date of Birth:
The application of Parent PLUS Loan funds that result in a refund are typically sent to the parent borrower. This consent
hereby authorizes Indian Hills Community College to refund to the above named student, any monies resulting from the
application of Parent PLUS Loan proceeds for the 2017-2018 academic year.
Signature of Parent Borrower
10/16
