Student Loan Repayment Loan Form Testing

OMB# 3170-0022
Exp. Date: 02/28/2019

CFPB Student Loans Payback Playbook (TO16) Disclosure Testing
Form Customization Worksheet

Participant ID

Round

Participant ID

Round

PLEASE NOTE: This information will only be used for
the purpose of creating a customized form for you to
use during the interview today. This information will
not be retained after today’s interview and will not
be associated with your name or personal
information.

PLEASE NOTE: This information will only be used for
the purpose of creating a customized form for you to
use during the interview today. This information will
not be retained after today’s interview and will not
be associated with your name or personal
information.

What is your current federal student loan
balance?

What is your current federal student loan
balance?

$__________________ Total Amount Owed (in dollars)

$__________________ Total Amount Owed (in dollars)

Please tell us about your family size.

Please tell us about your family size.

(Check all that apply)

(Check all that apply)

(Your best estimate to the nearest $1,000)

I have a spouse
I have children
Number of children__________________
I have other dependents I am responsible
for
Please list _____________________
I am expecting a child this year

(Your best estimate to the nearest $1,000)

I have a spouse
I have children
Number of children__________________
I have other dependents I am responsible
for
Please list _____________________
I am expecting a child this year

What is your annual income?

What is your annual income?

$_____________________________

$_____________________________

(Individual salary or income estimate to the nearest
$1,000)

(Individual salary or income estimate to the nearest
$1,000)

CFPB Student Loans Payback Playbook (TO16) Disclosure Testing
Form Customization Worksheet

OMB# 3170-0022
Exp. Date: 02/28/2019

Privacy Act Statement: The information you provide through your responses to Fors Marsh Group will assist the study
sponsor, the Consumer Financial Protection Bureau (CFPB), conduct a study that will focus on the development and
improvement of CFPB tools and resources to assist student loan borrowers. Information collected on behalf of the
Bureau by Fors Marsh Group will be treated in accordance with the System of Records Notice (SORN), CFPB.021 –
CFPB Consumer Education and Engagement Records, 77 F.R. 60382. This information will only be disclosed as outlined
in the Routine Uses for the SORN. Direct, identifying information will only be used to facilitate the study and will be
kept private except as required by law. This collection of information is authorized by Pub. L. No. 111-203, Title X,
Sections 1013 and 1022, codified at 12 U.S.C. §§ 5493 and 5512.Participation in this study is voluntary. You are not
required to participate or share any identifying information with Fors Marsh Group and you may withdraw
participation at any time. However, if you do not include the requested information, you may not participate in the
study.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and not withstanding any
other provision of law a person is not required to respond to a collection of information unless it displays a valid OMB
control number. The OMB control number for this collection is 3170-0022. It expires on 02/28/2019. The time
required to complete this information collection is estimated to average approximately 1 minute per response.
Comments regarding this collection of information, including the estimated response time, suggestions for improving
the usefulness of the information, or suggestions for reducing the burden to respond to this collection should be
submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW,
Washington, DC 20552, or by email to CFPB_PRA@cfpb.gov.