FORM APPROVED OMB No. 0915-0036 EXP DATE:
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U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
Bureau of Health Profession
Rockville, MD 20857
DATE OF REQUEST
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FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM
REQUEST FOR COLLECTION ASSISTANCE
(42 U.S.C. 292-2920)
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a valid OMB control number for this information collection is 0915-0036. The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. |
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FROM (Name of Lender) |
LENDER IDENTIFICATION |
SERVICER IDENTIFICATION |
TO: Debt Management Branch, PSC Health and Human Services 5600 Fishers Lane, Room 11-61 Rockville, MD 20857
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STREET ADDRESS |
CITY AND STATE |
ZIP CODE |
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NAME AND TITLE |
TELEPHONE |
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AREA CODE |
NUMBER |
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We request your assistance on the Delinquent Borrower below: |
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NAME OF BORROWER (Last, First, MI) |
DISCIPLINE
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SOCIAL SECURITY NUMBER
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TELEPHONE |
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AREA CODE |
NUMBER
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MAILING ADDRESS |
CITY |
STATE |
ZIP CODE
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LAST SCHOOL ATTENDED |
SCHOOL IDENTIFICATION |
SCHOOL DATE □ Graduation____________________________ □ Withdrawal____________________________ |
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NAME OF NEAREST RELATIVE |
ADDRESS |
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CITY
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STATE |
ZIP CODE |
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NAME OF PARENT OR GUARDIAN |
ADDRESS |
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CITY
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STATE |
ZIP CODE |
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ORIGINAL PRINCIPAL LOAN AMOUNT
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UNPAID PRINCIPAL AND INTEREST |
PERCENT INTEREST |
NUMBER OF PAYMENTS MADE TO DATE |
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REASON FOR THIS REQUEST (Check one) 1a. □ STUDENT IS DELINQUENT ON MONTHLY PAYMENTS 1b. REFINANCED LOAN Yes □ No □
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2. □ SKIP |
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3. □ OTHER (Explain) |
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WARNING: Any person who knowingly makes a false statement or misrepresentations in a HEAL loan transaction, bribes or attempts to bribe a Federal official, fraudulently obtains a HEAL loan, or commits any other illegal action in connection with a HEAL loan, is subject to possible fine(s) and imprisonment under Federal statute. |
HRSA-513 (9/05)
File Type | application/msword |
File Title | DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED: |
Author | Hrsa |
Last Modified By | CHaddad |
File Modified | 2011-08-22 |
File Created | 2011-08-22 |