Loan Discharge Application: False Certification (Unautho

OMB No. 1845-0015 Form Approved Exp. Date 10/31/2011

LOAN DISCHARGE APPLICATION: FALSE CERTIFICATION (UNAUTHORIZED SIGNATURE / UNAUTHORIZED PAYMENT) William D. Ford Federal Direct Loan Program / Federal Family Education Loan Program WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document will be 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

30-DAY DRAFT 10/14/2011

Please enter or correct the following information. Check this box if any information has changed. SSN |__|__|__|-|__|__|-|__|__|__|__|

Name

Address

City, State, Zip Code

Telephone - Primary ( )

Telephone - Alternate ( )

E-mail (optional)

_____________________________________

SECTION 2: STUDENT INFORMATION

Before completing this section, carefully read the entire form, including the instructions, definitions, and terms and conditions in Sections 4, 5, and 6 on this form. If you are a student borrower applying for loan discharge, begin with Item 3. If you are a parent borrower applying for a PLUS loan discharge, begin with Item 1.

1. Student Name (Last, First, MI):

2. Student SSN: |__|__|__|-|__|__|-|__|__|__|__|

3. School Name:

4. School Address (street, city, state, zip code):

5. Dates of attendance at the school:

From |__|__|-|__|__|-|__|__|__|__| To |__|__|-|__|__|-|__|__|__|__|

6. Did you sign the application, promissory note, master promissory note (MPN), or combined application/promissory note for your loan(s)? Yes No If No, on which document(s) did someone else sign your name? Application Promissory note MPN Combined application/promissory note

7. Did you endorse each loan check or sign your name on each electronic funds transfer authorization or master check authorization? Yes No Does Not Apply If No, on which document(s) did someone else sign your name? Loan check Electronic funds transfer authorization Master check authorization If No, did you (or, for a parent PLUS borrower, the student) ever receive any money from the school, or did the school ever reduce the amount of money that you (or, for a parent PLUS borrower, the student) owed to the school? Yes No Don’t Know If Yes, explain (give dates, amounts, and circumstances):

If No or Don’t Know, explain how you (or, for a parent PLUS borrower, the student) paid the tuition and fees owed to the school:

8. If you answered No to Item 6 or Item 7, do you know who signed your name on the document(s) checked in Item 6 or Item 7?

Yes No If Yes, identify the person who signed your name on the document(s).

School employee or representative (name and position):

Other person (name):

Provide any other information about the circumstances under which another person signed your name:

IMPORTANT: If you did not sign your name on one of the documents listed in Item 6 or Item 7, you must attach documents containing four other samples of your signature in addition to the signature on this application. At least two of these samples must clearly show that your signatures were written within one year before or after the date of the document on which someone else signed your name. Examples of documents that would include both a signature sample and the date that the signature was written include—but are not limited to—cancelled checks, tax returns, and driver’s licenses. If you do not provide these signature samples, you cannot be considered for a loan discharge.

9. Did the holder of your loan receive any money back (a refund) from the school on your behalf? Yes No Don’t Know

If Yes, give the amount and explain why the money was refunded:

10. Did you (or, for a parent PLUS borrower, the student) make any monetary claim with, or receive any payment from, the school or any third party (see definition in Section 5) in connection with enrollment or attendance at the school? Yes No Don’t Know If Yes, please provide the following information:

(a) Name/address/telephone number of the party with whom the claim was made or from whom payment was received:

(b) Amount/status of claim:

(c) Amount of payment received:

$

(Write “none” if no payment was received.)

SECTION 3: BORROWER CERTIFICATION AND AUTHORIZATION

My signature below certifies that – I have read and agree to the terms and conditions of this loan discharge, as specified in Section 6 on the following page. Under penalty of perjury, I certify that all of the information I have provided on this form and in any accompanying documentation is true and accurate to the best of my knowledge and belief. I authorize the school, the lender, the guaranty agency, the U.S. Department of Education, and their respective agents and contractors to contact me regarding this application at the current 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.

Borrower’s Signature:

Today’s Date:

SECTION 4: INSTRUCTIONS FOR COMPLETING THIS FORM
Type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only numbers. Example: June 24, 2011 = 06-24-2011. 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 account number on all attached pages. Return the completed form and any attachments to the address in Section 8.
SECTION 5: DEFINITIONS
 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 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 holder of your FFEL Program loan(s) may be a lender, a guaranty agency, or the U.S. Department of Education (the Department). The holder of your Direct Loan Program loan(s) is the Department.  Unauthorized signature means that the school, without the borrower’s authorization, signed the borrower’s name on a loan application or promissory note.  Unauthorized payment means that the school, without the borrower’s authorization, endorsed the borrower’s loan check or signed the borrower’s authorization for electronic funds transfer or master check, and did not give the loan proceeds to the borrower or apply the loan proceeds to charges owed by the student to the school.  Loan discharge due to an unauthorized signature on a loan application or promissory note cancels your obligation (and any endorser’s obligation, if applicable) to repay the remaining balance on a FFEL Program Loan or a Direct Loan Program Loan, and qualifies you for reimbursement of any amounts paid voluntarily or through forced collection on the loan. Discharge due to an unauthorized signature on a loan check, electronic funds transfer authorization, or master check authorization applies only to the amount of the unauthorized payment. For consolidation loans, only the loan amounts associated with the document listed in Section 2, Item 6 or Item 7, will be considered for discharge. The loan holder reports the discharge to all credit reporting agencies to which the holder previously reported the status of the loan.  The student refers to the student for whom a parent borrower obtained a Federal PLUS Loan or Direct PLUS Loan.  Third party refers to any entity that may provide reimbursement for a refund owed by the school, such as a State or other agency offering a tuition recovery program or a holder of a performance bond.
SECTION 6: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON FALSE CERTIFICATION (UNAUTHORIZED SIGNATURE/UNAUTHORIZED PAYMENT)
 The school identified in Section 2 of this form received FFEL Program or Direct Loan Program loan funds on or after January 1, 1986 for me to attend (or, if I am a parent PLUS borrower, for the student to attend) the school. I am applying for a discharge of my FFEL Program or Direct Loan Program loan(s) because the loan application, promissory note, master promissory note, combined application/promissory note, loan disbursement check, electronic funds transfer authorization, or master check authorization were not authorized for the reasons stated in this application.  Upon request, I will provide testimony, a sworn statement, or other documentation reasonably available to me that demonstrates to the satisfaction of the Department or its designee that I meet the qualifications for loan discharge based on unauthorized signature / unauthorized payment, or that supports any representation that I made on this form or on any accompanying documents.  I agree to cooperate with the Department or its designee in any enforcement action related to this application for loan discharge.  I understand that this application may be denied, or my discharge may be revoked, if I fail to provide testimony, a sworn statement, or documentation upon request, or if I provide testimony, a sworn statement, or documentation that does not support the material representations I have made on this form or on any accompanying documents.  I further understand that if my loan(s) is discharged based on any false, fictitious, or fraudulent statements that I knowingly made on this form or on any accompanying documents, I may be subject to civil and criminal penalties under applicable federal law.  I hereby assign and transfer to the Department any right to a refund on the discharged loan(s) that I may have from the school identified in Section 2 of this form and/or any owners, affiliates, or assigns 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).
SECTION 7: IMPORTANT NOTICES
Privacy Act Disclosure 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 20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Education Loan (FFEL) Program or the William D. Ford Federal Direct Loan (Direct Loan) 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 FFEL and/or Direct Loan 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) become delinquent or in 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 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 status, 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 it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 0.5 hours (30 minutes) per response, including the time to reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and completing and reviewing the information collection. Individuals are obligated to respond to this collection to obtain a benefit in accordance with 34 CFR 682.402(e)(3) and 34 CFR 685.215(c). Send comments regarding the burden estimate(s) or any other aspect of this collection, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC 20210-4537, or e-mail ICDocketMgr@ed.gov and reference OMB Control Number 1845-0015. Note: Please do not return the completed Loan Discharge Application to this address. .
SECTION 8: WHERE TO SEND THE COMPLETED LOAN DISCHARGE APPLICATION
Return the completed loan discharge application and any attachments 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.)

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