513 Form

FORM APPROVED

OMB No. 1845-0127

EXP DATE:

U. S. DEPARTMENT OF EDUCATION

Federal Student Aid

DATE OF REQUEST

FEDERAL HEALTH EDUCATION ASSISTANCE LOAN (HEAL) PROGRAM

REQUEST FOR COLLECTION ASSISTANCE

(42 U.S.C. 292-2920) and the Consolidated Appropriation Act, 2014

PRA Burden Statement: 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 1845-0127. Public reporting burden for this collection of information is estimated to average 10 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 or retain benefit (Title VII, Part A, Subpart I of the Public Health Service Act (42 U.S.C. 294m) and the Consolidated Appropriations Act, 2014). If you have comment or concerns regarding the status of your individual submission of this form, please contact the HEAL Program, U.S. Department of Education, 830 First Street NE, Washington, DC, 20202 directly. [Note: Please do not return the completed form to this address.]

FROM (Name of Lender)

LENDER

IDENTIFICATION

SERVICER IDENTIFICATION

TO: Department of Education,

Program Support Center (PSC)

12501 Ardennes Ave., Suite 100

Rockville, MD 20857

STREET ADDRESS

CITY AND STATE

ZIP CODE

NAME AND TITLE

TELEPHONE

AREA CODE

NUMBER

We request your assistance on the Delinquent Borrower below:

NAME OF BORROWER (Last, First, MI)

DISCIPLINE

SOCIAL SECURITY NUMBER

TELEPHONE

AREA CODE

NUMBER

MAILING ADDRESS

CITY

STATE

ZIP CODE

LAST SCHOOL ATTENDED

SCHOOL IDENTIFICATION

SCHOOL DATE

□ Graduation____________________________

□ Withdrawal____________________________

NAME OF NEAREST RELATIVE

ADDRESS

CITY

STATE

ZIP CODE

NAME OF PARENT OR GUARDIAN

ADDRESS

CITY

STATE

ZIP CODE

ORIGINAL PRINCIPAL LOAN AMOUNT

UNPAID PRINCIPAL AND INTEREST

PERCENT INTEREST

NUMBER OF PAYMENTS MADE TO DATE

REASON FOR THIS REQUEST (Check one)

1a. □ STUDENT IS DELINQUENT ON MONTHLY PAYMENTS 1b. REFINANCED LOAN Yes □ No □

NUMBER OF PAYMENTS

AMOUNT DUE PER MONTH $

2. □ SKIP

3. □ OTHER (Explain)

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.

HEAL-513