OMB No. 1845-0127 EXP DATE: Form Under Review |
U. S. DEPARTMENT OF
EDUCATION
Federal Student Aid
DATE OF REQUEST
|
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) Accounting Services – Debt Collection 7700 Wisconsin Avenue, Mail Stop 10230B Suite 8-8110D Bethesda, 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 □
|
|||||||||||||||||
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
File Type | application/msword |
File Title | DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED: |
Author | Hrsa |
Last Modified By | Ingalls, Katrina |
File Modified | 2017-05-31 |
File Created | 2017-05-31 |