Form 2 Form 510

LENDER'S APPLICATION FOR INSURANCE CLAIM ON A FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL)

FORM APPROVED:

OMB NO.0915-0036 Exp. Date:

WARNING: Any person who knowingly makes a false statement or misrepresentation 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 and imprisonment under Federal Statue.

1a. Holder Information

1b. Servicer Information

Holder ID Number: ______________________________________________ Holder Name: __________________________________________________ Address: ______________________________________________________ City/State/Zip Code:__________________________________________ Telephone No.: ___________________ Fax: _________________________

Servicer ID Number: ________________________________________________ Servicer Name: ____________________________________________________ Address: __________________________________________________________ City/State/Zip Code:________________________________________________ Telephone No.: ____________________ Fax: _____________________

Original Claim Submission Yes □ No □ If no, date on HHS letter rejecting original claim submission:

1c. Claim Type

Judgment □

Bankruptcy Chapter 11 □

Bankruptcy Chapter 13 □

Bankruptcy Adversary □

Skip □

Unable to Serve □

Disability □

Death □

Low Loan □

Low Balance □

2. Borrower Information

Borrower Name (Last, First , M.I.)

Social Security No.

Last Known Address

City

State Or Country

Zip Code

3. Heal Loan Information and Documentation (Complete all columns for each loan listed.)

Loan ID Number

Original Loan Amount Guaranteed

Amount Disbursed

Promissory Note (Check one column)

Application (Check one column)

Repayment Schedule

Payment History (Check for Yes)

Principal & Interest Worksheet (Check for Yes)

No. of Months in Deferment

No. of Months in Forbearance

Original

Copy with Affidavit

Original

Copy

Copy

Affidavit

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HRSA — 510 Rev.9/2008 PAGE 1

Borrower Name (Last, First, M.I.)

Social Security No.

4. Claim Information

Borrower School Separation Date

Repayment Begin Date

Refinanced Loan? Yes □ No □

Most Recent Delinquency Date

Reported Credit Bureau Date

Due Diligence Letter 1 Date

Due Diligence Letter 2 Date

Due Diligence Letter 3 Date

Due Diligence Letter 4 Date

Prior Bankruptcy? Yes □ No □

PCA 90 Day Letter Date

PCA 120 Day Letter Date

PCA 150 Day Letter Date

Final Demand Date

5. Judgment Claim

Litigation Began Date

Litigation ID Number

Judgment Date

Judgment Assignment Date

Exemplified or Certified Judgment Received Date

Post-Judgment Interest Rate (Percent Only)

Continuing Interest Clause? Yes □ No □

6. Bankruptcy Claim (All Bankruptcy claims must be filed within 10 days of notification and include required documentation.)

Official Notification of Bankruptcy Date

First Meeting of Creditors Included? Yes □ No □

Proof of Claim Included? Yes □ No □

Transfer of Proof of Claim? Yes □ No □

Copy of Bankruptcy Plan Included? Yes □ No □

Adversary Only

Basis for Objection Included? Yes □ No □

Copy of Complaint? Yes □ No □

Complaint Date

Copy of Summons? Yes □ No □

Adversary Received Date

7. Skip

8. Unable to Serve

Skip Tracing Began Date

Determination Date

No. of Attempts to Serve

Was Service Attempted by Officers of the Court (Public Service)? Yes □ No □

Return of Service? Yes □ No □

Last Attempt Date

Copy of Complaint Included? Yes □ No □

9. Disability

Notified of Disability Date

Package Sent to HHS Date

HHS Approval Date

10. Death

Notified of Death Date

Official Notification of Death Received Date

11. Low Loan

12. Low Balance

All Loans Made Prior to 11/14/88 <$5000? Yes □ No □

All Loans Made on After 11/4/88 <$2500? Yes □ No □

Claim Amount <$1000? Yes □ No □

13. Total Amount of Insurance Claim (Principal and Interest): $__________________________ I certify that the information on this form is correct. I have used standard commercial collection practices and conformed to the due diligence standards of the HEAL regulations and policy guidelines. The borrower is not entitled to the deferment of principal, as provided in the Promissory Note(s). Any further payments by the borrower will be sent to the Public Health Service.

FOR PHS USE ONLY

14a. Signature of Authorizing Official

14b. Name and Title (Please Print)

14c. Date

HRSA — 510 Rev.9/2008

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