1845-0053 Federal Direct Consolidation Loan Add Loan Listing Sheet

Direct Consolidation Loan Request to Add Loans

William D. Ford Federal Direct Loan Program FINAL FOR OMB APPROVAL 04/12/2016

OMB No. 1845-0053

Form Approved

Exp. Date xx/xx/xxxx

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or 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.

Before You Begin

Read the Instructions on page 2 before completing this form.

Borrower Information

1. Last Name: ______________________________________________ First Name: ___________________________________________ Middle Initial: __________

2. Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

LOANS YOU WANT TO CONSOLIDATE

3. Loan Code (see Instructions)	4. Loan Holder/Servicer Name, Address, and Area Code/Telephone Number (see Instructions)	5. Loan Account Number	6. Estimated Payoff Amount

PROMISSORY NOTE ADDENDUM

• I request that the U.S. Department of Education (ED) pay in full the eligible federal education loans identified above in the Loans You Want to Consolidate section and that the amount of my Direct Consolidation Loan be increased to include the amount paid by ED.

• If my Direct Consolidation Loan has already been made, I understand that ED must receive this request within 180 days of the date my Direct Consolidation Loan was made. I further understand that by adding these loans my repayment term may be extended, my interest rate may change, and my monthly payment amount may change. I will receive a revised disclosure statement and repayment schedule from ED.

• My signature below certifies that I have read, understand, and agree to the terms and conditions of this loan, including all terms and conditions specified on the Direct Consolidation Loan Application and Promissory Note (Note) that I previously submitted, including the Borrower Understandings, Certifications and Authorizations, and the Borrower’s Rights and Responsibilities Statement.

I UNDERSTAND THAT THIS IS A LOAN THAT I MUST REPAY.

7. Borrower’s Signature ____________________________________________________________ Today’s Date (mm-dd-yyyy) ___ ___ - ___ ___ - ___ ___ ___ ___

INSTRUCTIONS FOR COMPLETING THE DIRECT CONSOLIDATION LOAN REQUEST TO ADD LOANS

BEFORE YOU BEGIN

Use this form if you would like to add one or more eligible federal education loans to your Direct Consolidation Loan, if the loan has already been made, or to the Note you previously submitted. Note: If your Direct Consolidation Loan has already been made, you must return this completed form to your Servicer at the address listed on this page within 180 days after the date your Direct Consolidation Loan was made. If you want to consolidate additional eligible loans after this period of time, you must apply for a new Direct Consolidation Loan.

To complete this form, type or print using blue or black ink. If you cross out anything and write in new information, put your initials beside the change. Incorrect or incomplete information may delay processing.

BORROWER INFORMATION

Items 1 and 2: Enter the requested information.

LOANS YOU WANT TO CONSOLIDATE

Items 3-6: Enter the requested information for each of the federal education loans that you want to add to your Direct Consolidation Loan (or to the Note you have submitted). To find the information you will need to complete this section, you can look at the last monthly billing statement you received, your quarterly interest statement or annual statement, your coupon book, or the Internet site of your loan holder or servicer. You may also obtain information about your loans by accessing the National Student Loan Data System (NSLDS) at www.nslds.ed.gov. If you need more space to list your loans, attach an additional sheet of paper to this form. Put your name, Social Security Number, and loan information on the paper.

Item 3: Enter the code that corresponds to the loan type from the list of loan types and their codes in these instructions. If you are not sure about the loan type, leave this item blank. Loan types not included in the list are not eligible for consolidation.

Item 4: Enter the full name and mailing address of the loan holder or the loan holder’s servicer. (This is the address to which you must send your payments.) You must provide at least the name, city, and state of the loan holder or servicer.

Item 5: Enter the account number for each loan (the number should be on your statement or in your payment book). If you cannot find the account number, leave this item blank.

Item 6: Enter the estimated amount needed to pay off the loan, including any unpaid interest, late fees, and collection costs.

PROMISSORY NOTE ADDENDUM

Item 7: Carefully read this section. Sign and date the form using blue or black ink. If you do not sign this form, your request cannot be processed.

Final Notes

Review all the information on the form. When you have completed the form, make a copy for your records and mail the original to us in the envelope provided, at the address shown on this page.

As soon as we receive your completed form, we will begin processing your request to add loans. During this time, we might contact you with questions.

In the meantime, if you currently are required to make payments on your loans, continue to do so. You will need to continue making payments until you receive written notification that your loans have been successfully added to your Direct Consolidation Loan. If you are having difficulty making payments on your loans, contact your loan holder or servicer at the correspondence address or telephone number on your current loan statements to find out ways you might be able to postpone loan payments; you should ask specifically about your “deferment” and “forbearance” options.

IMPORTANT: We will send you a notice before we pay off your loans. This notice will:

1. Provide you with information about the loans and payoff amounts that we have verified with your loan holder(s) or through NSLDS, and

2. Tell you the deadline by which you must notify us if you do not want to add one or more of the loans listed in the notice to your Direct Consolidation Loan.

The notice will include information about the loans you listed in the Loans You Want to Consolidate section. If you have additional loans that are with a holder of a loan listed in the Loans You Want to Consolidate section, but you did not list those loans in that section, the notice may also include information about those additional eligible loans. For example, if you have two Subsidized Federal Stafford Loans with Loan Holder A, but you listed only one of these loans in the Loans You Want to Consolidate section, the notice that we send may include information about both of your Subsidized Federal Stafford Loans that are with Loan Holder A. You must inform us by the deadline specified in the notice if you do not want all of the loans listed in the notice to be consolidated.

LOAN TYPES AND THEIR CODES

Code	Loan Type
A	Subsidized Federal Stafford Loans
B	Guaranteed Student Loans (GSL)
C	Federal Insured Student Loans (FISL)
D	Direct Subsidized Loans
E	Direct Subsidized Consolidation Loans
F	Federal Perkins Loans
G	Unsubsidized Federal Stafford Loans (including Nonsubsidized Stafford Loans)
H	Federal Supplemental Loans for Students (SLS)
I	Direct PLUS Loans for Graduate/Professional Students
J	Unsubsidized Federal Consolidation Loans
K	Direct Unsubsidized Consolidation Loans
L	Direct Unsubsidized Loans
M	National Direct Student Loans (NDSL)
N	National Defense Student Loans (NDSL)
O	Subsidized Federal Consolidation Loans
P	Auxiliary Loans to Assist Students (ALAS)
Q	Health Professions Student Loans (HPSL)
R	Health Education Assistance Loans (HEAL)
S	Federal PLUS Loans for Graduate/Professional Students
T	Federal PLUS Loans for Parents
U	Direct PLUS Loans for Parents
V	Direct PLUS Consolidation Loans
Y	Nursing Student Loans (NSL) and Nurse Faculty Loans
Z	Loans for Disadvantaged Students (LDS)
W	Education loans ineligible for consolidation
0	Direct Subsidized Loans (Subsidy Loss Eligible)
9	Direct Subsidized Consolidation Loans (Subsidy Loss Eligible)

WHERE TO SEND YOUR COMPLETED REQUEST TO ADD LOANS

Mail the completed form to the following address:

[INSERT SERVICER ADDRESS]

For help completing this form, call [INSERT SERVICER #].

For the hearing impaired, the TDD number is [INSERT SERVICER TDD #].

DIRECT CONSOLIDATION LOAN REQUEST TO ADD LOANS: 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 authority for collecting the requested information from and about you is §451 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in 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 Direct Loan Program, 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.

Financial Privacy Act Notice

Under the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401-3421), ED will have access to financial records in your student loan file maintained in compliance with the administration of the Direct Loan Program.

Paperwork Reduction Notice

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless the collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0053. Public reporting burden for this collection of information is estimated to average 10 minutes (0.17 hours) 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 685.201(c)(1).

If you have comments or concerns regarding the status of your individual submission of this form, contact:

[INSERT SERVICER ADDRESS]

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