Fillable Total And Permanent Disability Discharge Post Discharge Monitoring Tcm5 1853 (Navient)

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Total And Permanent Disability Discharge Post Discharge Monitoring Tcm5 1853 (Navient)

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SECTION 1: DISCHARGE RECIPIENT INFORMATION
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
Email (Optional)
TPD-PDM
POST-DISCHARGE MONITORING: TOTAL AND
PERMANENT DISABILITY
William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan)
Program / TEACH Grant Program
OMB No. 1845-0065
Form Approved
Exp. Date 09/30/2019
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 2: DOCUMENTATION OF EARNED INCOME
Carefully read the entire form. Type or print in dark ink. Sign and date the form in Section 3. Include your name and Social
Security Number on any documentation that you submit with this form. Submit this form to the address in Section 6.
Page 1 of 4
Your obligation to repay a discharged loan or complete a discharged TEACH Grant service obligation will be reinstated if you
receive annual earnings from employment above the poverty guideline for a family size of two, regardless of your actual
family size, for any of the three years following the date that your loans and/or service obligations were discharged. The
poverty guidelines are issued annually by the U.S. Department of Health and Human Services, and are available at:
aspe.hhs.gov/poverty. For 2016, the poverty guidelines for a family size of two are:
Family Size 48 States & DC Alaska Hawaii
2 $16,020 $20,020 $18,430
Did you have income earned from employment between
and
?
Yes - You must provide documentation of all income you receive from employment or self-employment. See below.
No - By signing this form, you are certifying that you had no earned income from employment during the period
identified above. Continue to Section 3.
Acceptable Documentation of Earned Income
• You must provide one piece of supporting documentation for each source of income earned from employment. For
example, documentation includes a federal or state income tax return, a W-2, a federal income tax return transcript, an
earnings statement from the Social Security Administration, an earnings statement from a state or local agency, or a
pay stub from any employment.
Unless the frequency is clearly indicated on the documentation that you provide, write on your documentation how
often you receive the income, for example, “twice per month” or “every other week”.
•
If you are submitting documentation of income that you receive on a calendar-year basis, but a portion of the income
in the documentation is outside of the period for which you are providing documentation, write on your
documentation the amount of the income that you received during the period identified above.
•
Copies of original documentation are acceptable.
•
If no documentation of your earned income is available, submit a signed statement explaining the amount and
source of your earned income.
•
Do not provide documentation of unearned income, such as income from interest or dividends. Do not report
untaxed income, such as Supplemental Security Income, child support, or federal or state public assistance.
If you do not live in one of the 50 states or DC, we
will use the poverty guideline for the 48 states.
NOTE: You may designate someone to represent you in matters related to your application. If you wish to designate a
representative, you must complete the Applicant Representative Designation: Total and Permanent Disability form.
Representative Name (if applicable)
Date Recipient's or Representative's Signature
I certify that all of the information I have provided on this form and in any accompanying documentation is true, complete,
and correct to the best of my knowledge and belief.
I receive annual earnings from employment that exceed the poverty guideline amount for a family of two in my state,
regardless of my actual family size;
1.
I understand that I may be required to repay my discharged loans and/or complete my discharged TEACH Grant service
obligation if, during the three-year post-discharge monitoring period, which begins on the date that I receive a discharge:
SECTION 3: RECIPIENT'S UNDERSTANDINGS AND CERTIFICATION
Recipient SSNRecipient Name
I receive a new loan under the Direct Loan or Perkins Loan Program or a new TEACH Grant; 2.
I receive a disbursement of a Direct Loan, Perkins Loan, or TEACH Grant that was initially disbursed prior to my discharge
date and I fail to ensure that the disbursement is returned to the loan holder or (for a TEACH Grant) to the U.S.
Department of Education within 120 days of the disbursement date; or
3.
The Social Security Administration determines that I am no longer disabled or changes my continuing disability review
period to a period that is shorter than 5-7 years or more, after I had been previously determined to be disabled by the
Social Security Administration and was receiving SSDI or SSI benefits with a continuing disability review period of 5-7
years or more.
4.
SECTION 4: DEFINITIONS
A discharge due to a total and permanent disability
cancels your obligation (and, if applicable, an endorser's
obligation) to repay the remaining balance on your
discharged loans or to satisfy your discharged TEACH Grant
service obligation.
The post-discharge monitoring period begins on the
date the U.S. Department of Education grants a discharge of
your loan or TEACH Grant service obligation and lasts for three
years. If you fail to meet certain conditions at any time during
or at the end of the post-discharge monitoring period, the U.S.
Department of Education will reinstate your obligation to
repay your loan or complete your TEACH Grant service
obligation. See Section 5 for more information.
The William D. Ford Federal Direct Loan (Direct Loan)
Program includes Direct Subsidized Loans, Direct
Unsubsidized Loans, Direct PLUS Loans, and Direct
Consolidation Loans.
The Federal Perkins (Perkins) Loan Program
includes Federal Perkins Loans, National Direct Student
Loans (NDSL), and National Defense Student Loans
(Defense Loan).
The Teacher Education Assistance for College and
Higher Education (TEACH) Grant Program requires
individuals to complete a teaching service obligation as
a condition for receiving a TEACH Grant.
A representative is a member of your family, your
attorney, a law firm or legal aid society, or another
individual or organization authorized to act on your
behalf in connection with your total and permanent
disability discharge application.
Page 2 of 4
SECTION 5: IMPORTANT INFORMATION ABOUT THE POST-DISCHARGE MONITORING PERIOD
Post-discharge monitoring period
If you were granted a discharge, we will monitor your
status during the 3-year post-discharge monitoring period
that begins on the date the discharge is granted. We will
reinstate your obligation to repay your loan(s) and/or to
complete your TEACH Grant service if, at any time during the
post-discharge monitoring period, you:
•
Receive annual earnings from employment that
exceed the poverty guideline amount for a family of
two in your state, regardless of your actual family size;
Receive a new loan under the Direct Loan Program or
Perkins Loan Program, or a new TEACH Grant;
Receive a disbursement of a Direct Loan, Perkins Loan,
or TEACH Grant that was initially disbursed prior to
your discharge date and fail to ensure that the
disbursement is returned to the loan holder or (for a
TEACH Grant) to us within 120 days of the
disbursement date; or
•
•
Page 3 of 4
If your discharge was based on Social Security
Administration (SSA) documentation, you receive a
notice from the SSA indicating that you are no longer
disabled or that your continuing disability review will
no longer be 5 to 7 years or more from the date of
your last SSA disability determination.
•
During the 3-year post-discharge monitoring period, we
will monitor the National Student Loan Data System (NSLDS)
to determine whether you have received a new loan under
the Direct Loan Program or the Perkins Loan Program or a
TEACH Grant, or whether you have failed to ensure that a loan
or TEACH Grant disbursement was returned to the loan holder
or (for a TEACH Grant) to us within 120 days of the
disbursement date.
During the 3-year post-discharge monitoring period, you
(or your representative) must:
Promptly notify us if your annual earnings from
employment exceed the poverty guideline amount
for a family of two in your state, regardless of your
actual family size;
•
•
Promptly notify us of any changes in your address or
telephone number;
Provide us with documentation of your annual
earnings from employment, on a form that we will
provide; and
•
If your discharge was based on SSA documentation,
promptly notify us if the SSA determines that you are
no longer disabled or changes your continuing
disability review period to a period that is shorter than
5 to 7 years.
•
Reinstatement of obligation to repay a loan or complete a
TEACH Grant service obligation
If you do not meet the requirements outlined above at any
time during or at the end of the post-discharge monitoring
period, we will reinstate your obligation to repay your loans
and/or to complete your TEACH Grant service.
If your loan is reinstated, you will be responsible for
repaying your loans to us in accordance with the terms of
your promissory note(s). Your loans will be returned to the
status that would have existed if we had not received your
total and permanent disability discharge application.
However, you will not be required to pay interest on your
loans for the period from the date of the discharge until the
date your repayment obligation was reinstated. We will be
your loan holder.
If your TEACH Grant service obligation is reinstated, you
will again be subject to the requirements of your TEACH Grant
Agreement to Serve. If you do not meet the terms of that
agreement and the TEACH Grant funds you received are
converted to a Direct Unsubsidized Loan, you must repay that
loan in full, and interest will be charged from the date(s) that
the TEACH Grant funds were disbursed.
If your obligation to repay your loans or complete your
TEACH Grant service obligation is reinstated, we will notify
you of the reinstatement. This notification will include:
The reason or reasons for the reinstatement;
•
For loans, an explanation that the first payment due
date on the loan following the reinstatement will be
no earlier than 60 days following the date of the
notification of reinstatement; and
•
Information on how you may contact us if you have
questions about the reinstatement, or if you believe
that your obligation to repay a loan or complete
TEACH Grant service was reinstated based on
incorrect information.
•
SECTION 7: 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., §451 et seq., §461, or
§420L of the Higher Education Act of 1965, as amended (20
U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa
et seq., or 20 U.S.C. 1070g 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 Direct
Loan,FFEL, Perkins Loan, or TEACH Grant 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, FFEL, Federal Perkins
Loan or TEACH Grant 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
1845-0065. 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 a benefit in accordance with
34 CFR 674.61(b) or (c), 34 CFR 682.402(c)(2) or (c)(9), 34 CFR
685.213(b) or (c), and 34 CFR 686.42(b). If you have
comments or concerns regarding the status of your
individual submission of this form, please contact the U.S.
Department of Education directly (see Section 6).
SECTION 6: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to: If you need help completing this form, contact us:
U.S. Department of Education - TPD Servicing
P.O. Box 87130
Lincoln, NE 68501-7130
Fax to: 303-696-5250
Email to: disabilityinformation@nelnet.com
Phone: 1-888-303-7818 (TTY: dial 711, then phone no.)
Email: disabilityinformation@nelnet.com
Website: www.disabilitydischarge.com
Page 4 of 4
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Completed 18 July 2020

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