ev-wy-attestation-form Edits from 30D comments CLEAN

UNITED STATES DEPARTMENT OF EDUCATION
ATTESTATION FOR CERTAIN EVEREST AND WYOTECH BORROWERS
APPLICATION FOR BORROWER DEFENSE TO REPAYMENT LOAN DISCHARGE

FORM Under Review
OMB NO: 1845-0132
Exp. XX/XX/XXXX

The Department of Education has found that at various times between 2010 and 2014, Everest Institute, Everest College, and Everest
University ("Everest"), and WyoTech published misleading job placement rates for many of its programs of study. This form is designed to
expedite the process of obtaining loan forgiveness based on borrower defense to repayment for loans taken out by Everest and WyoTech
borrowers to enroll in these programs. This form covers federal Direct Loans (including Parent PLUS loans issued to parents of Everest
and WyoTech students) received on or after July 1, 2010. A list of covered programs and dates of enrollment is available at
StudentAid.gov/ev-wy-findings. Please fill out this attestation ONLY IF your program and dates of enrollment are included on this list.
Everest and WyoTech students and, if applicable, parents with Parent PLUS loans who did not attend programs where the Department of
Education found misleading job placement rates, or whose decision to enroll was not influenced by those job placement rates, may still be
eligible for loan forgiveness based on borrower defenseto repayment. Additional instructions to file a claim for loan forgiveness can be found
at StudentAid.gov/borrower-defense.
Instructions: Please complete this form (students and, if applicable, parents with Parent PLUS loans). To sign the form, insert a digital image
of your signature in the appropriate field below or print a hard copy of the form and sign. Submit your form and all supplementary documents
referenced in question #4 via email to BorrowerDefense@ed.gov or mail to U.S. Department of Education - Borrower Defense to Repayment,
PO Box 1854, Monticello, KY 42633.
SECTION I: BORROWER INFORMATION
First Name

Middle Name

Home Address

City

I,

Last Name

Date of Birth

State

Zipcode

, attest to the following:

I am submitting this attestation and additional materials in support of my application for a borrower defense to repayment discharge of my
Direct Loans under 34 C.F.R. §§ 685.206(c), 685.206(d), 685.222(d).
SECTION II: PROGRAM INFORMATION
If you, or your child in the case of Parent PLUS loans, enrolled in more than one covered Everest/WyoTech program, you will need to
complete the following for each covered program you, or your child, attended. For example, if you, or your child, were a criminal justice
student in 2011 and returned in 2012 for an accounting program, you should completethe first Campus Program section based on your, or
your child’s, enrollment in criminal justice and the second Campus Program section based on your, or your child’s, enrollment in
accounting.
If you, or your child in the case of Parent PLUS loans, have more than one program, click the Add Campus Program button that appears at the
bottom of the Campus Program section.
Note: This form applies to students and, if applicable, parents with Parent PLUS loans who enrolled in a program after misleading
placement rates were published for the program. A list ofcovered programs and dates of enrollment is available at StudentAid.gov/ev-wyfindings. The earliest enrollment date covered is July 1,2010.

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CAMPUS PROGRAM
Campus

Enrollment Start Date* (MM/YYYY)

Program
Name
1.

Enrollment End Date* (MM/YYYY)

Credential

Prior to my, or my child’s, enrollment in this Everest/WyoTech program, I received information about job placement rates related to
my program ofstudy through one or more of the following ways (check each that applies)
Brochures advertising Everest/WyoTech academic programs or other printed materials, including those provided by Everest/
WyoTech representatives or recruiters;
Emails, online materials, or online disclosures from or by Everest/WyoTech.

2.

I believed that the job placement rates related to my, or my child’s, program of study indicated the level of quality an Everest/WyoTech
education offeredto students. I, or my child, chose to enroll at Everest/WyoTech based, in substantial part, on the information I, or my child,
received about job placement rates relatedto my, or my child’s, program of study and the quality of education I, or my child, believed those
placement rates represented.

3.

I applied for and received a federal Direct Loan to cover the cost of attendance of the Everest/WyoTech program in which I, or my child,
enrolled.

4.

As an attachment to this attestation, I have included documents with additional information to confirm that I, or my child, was enrolled
in the programof study at Everest/WyoTech that I identified above, and was enrolled for the dates I provided above. Suggested
documents include transcripts and registration documents indicating your, or your child’s, specific program of study at
Everest/WyoTech and dates of enrollment. The documents I have attached are:

*Select the check box if you had multiple periods of enrollment in a program, that is, if you, or your child, enrolled in a program but
subsequently
discontinued enrollment, and then reenrolled in the same program at a later date, please provide all start and end dates
applicable to this program. (Deselect the check box to remove any enrollment dates added in error.)
Add Campus Program

Remove Campus Program

SECTION III: OTHER INFORMATION
Please provide or attach any other information about your experience at Everest/WyoTech that you believe is relevant: (2,000 characters max)

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SECTION IV: DIRECT LOAN FORBEARANCE
By completing this form, you are eligible to have all of your federal loans placed into forbearance and for collections on any federal loans in
default to stop while your claim is reviewed by the Department of Education. Please read the following information carefully before making
your selection below.
During any period that your loans are in forbearance, you do not have to make payments on those loans, and the loans will not go into default.
If your loans are already in default, collections will stop. This will continue until the loan discharge review process is completed. Your servicer
will notify you when your loan has been placed into forbearance or stopped collections. Until you receive that notice, you should continue to
make payments.
The forbearance or stopped collections will affect all of a borrower's federal loans, including loans that are not eligible for discharge through
this form, such as Federal Family Education Loans (FFEL), loans taken out to attend an Everest and/or WyoTech program not on the enclosed
list of covered programs, or loans taken out to attend another institution.
Note that interest will continue to accrue on all of these federal loans, including subsidized loans, during the forbearance or stopped
collections period.
If you want the forbearance or stopped collections to apply only to those loans that may be eligible for a discharge using this form, you must
notify your loan servicer. At any time during the forbearance or stopped collections period, you may voluntarily make payments on your
loans, including payments for accrued interest, or end the forbearance or stopped collections by contacting your servicer.
If your claim made using this form is successful, your federal Direct Loans borrowed to attend a covered Everest/WyoTech program will be
discharged. Also at that time, the forbearance or stopped collections period for your other federal loans will end. You will be responsible for
repaying these other remaining loans, including interest that accrued during the forbearance or stopped collections period, under the terms of
your promissory note.
If your claim is denied, you will not receive a discharge of any of your loans and the forbearance or stopped collections period will end for all
of your loans. You will be responsible for repaying these loans, including interest that accrued during the forbearance or stopped collections
period, under the terms of your promissory note.
Yes, I want my federal loans to be placed in forbearance and for collections to stop on any loans in default while my loan discharge
claim is reviewed.
No, I do not want my federal loans to be placed in forbearance and for collections to stop on any loans in default while my loan
discharge claim is reviewed.
SECTION V: CERTIFICATION
By signing this attestation, I certify that:
I agree to provide, upon request, testimony, a sworn statement, or other documentation reasonably available to me that demonstrates to the
satisfaction of the Department of Education or its designee that I meet the qualifications for borrower defense to repayment loan discharge.
All of the information I provided is true and complete to the best of my knowledge and I agree, if asked, to provide information reasonably
available to me to the Department of Education that will verify the accuracy of my completed attestation.
I understand that the Department of Education has the authority to verify information reported on this application with other federal or state
agencies or other entities. I authorize the Department of Education, along with its agents and contractors, to contact me regarding this request
at the phone number above using automated dialing equipment or artificial or prerecorded voice or text messages.
I understand that if I purposely provided false or misleading information on this application, I may be subject to the penalties specified in 18
U.S. Code § 1001.

Signature

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PRIVACY ACT STATEMENT
Information required by subsection (e)(3) of the Privacy Act of 1974, as amended (Privacy Act) (5 U.S.C. 552a(e)(3))requires
the following notice be provided to you:
The authorities for collecting the requested information from and about you are Section 455(h) of the Higher Education Act
of 1965, as amended (HEA) (20 U.S.C. 1087e(h)) and 34 C.F.R. § 685.206(c) and the authorities for collecting and using your
Social Security Number (SSN) are the same but also include 31 U.S.C. 7701(b). The primary purpose of the information
collected is for the use and administration of the U.S. Department of Education's office of Federal Student Aid (ED/we) for
borrower defense to loan repayment program. The information you provide ED on this form and your SSN are voluntary, but
you may need to provide the requested information on this form, including your SSN and/or a Federal Student Aid ID (FSA
ID) that provides ED your verified SSN and other individual information pertaining to a student's or parent's Student
Financial Assistance Programs account(s), for ED to process or complete our review of your borrower defense to loan
repayment application. You may submit a form without your SSN or an FSA ID by filling out a form and sending it to ED via
email or physical mail because disclosure of the information requested on this form is voluntary. However, without providing
all the requested information on this form, ED may not be able to conduct a full investigation and complete the review of
your application.
We use the information that you provided on this form including your name, SSN, date of birth, address, email address,
telephone number(s), and / or an FSA ID, to receive, review, evaluate, and process requests for relief under the borrower
defense to loan repayment regulations, to render decisions on the merits of such requests for relief, and, where requests for
borrower defense to loan repayment are successful, to determine the relief that is appropriate to borrowers under the
circumstances as well as to initiate appropriate proceedings to require schools whose acts or omissions resulted in the
successful defenses against repayment to pay ED the amounts of the loans that apply to the defenses. Without your consent,
ED may disclose the information that you provided and as otherwise allowed by the Privacy Act, pursuant to the routine uses
identified in the system of records notice (SORN) entitled “Customer Engagement Management System (CEMS)” (18-11-11)
and published in the Federal Register as 83 FR 27587-27591 (June 13, 2018). These routine uses include, but are not limited
to, a routine use that permits ED to disclose your information to foreign agencies, Federal agencies, State agencies, Tribal, or
local agencies, accreditors, schools, lenders, guaranty agencies, servicers, and private collection agencies when further
information is relevant to ED's resolution of your complaint, request, or other inquiry, tracking your application or your
inquiry, and, where a request for borrower defense to loan repayment is successful, to determine the relief that is appropriate
under the circumstances as well as to initiate the appropriate proceeding to require the school whose acts or omissions
resulted in the successful defense against loan repayment to pay ED the amount of the loan that apply to the defenses. We
may use your information for reporting, analyzing the data to make recommendations in student financial assistance
programs, and assisting in the informal resolution of disputes. Disclosure of relevant information also may be made to the
responsible foreign, Federal, State, Tribal or local agencies charged with investigating or prosecuting a violation or potential
violation of law in the event that information indicates, either on its face or in connection with other information, a violation
or potential violation of any applicable statute, regulation, or order of a competent authority.
In the event of litigation or alternative dispute resolution (ADR) involving ED or that we have an interest in and if that a party
is either any component of ED, any ED employee in his or her official capacity, any ED employee in his or her individual
capacity where representation for the employee has been requested or has been agreed to by ED or the Department of Justice
(DOJ), or the United States where ED determines that the litigation is likely to affect ED or any of its components, we may
disclose your information to DOJ, a court, adjudicative body, a person or an entity designated by ED or otherwise empowered
to resolve or mediate disputes, or a counsel, party, representative, or witness if the disclosure is relevant and necessary to the
litigation or ADR. ED also may disclose your information to DOJ to the extent necessary for obtaining DOJ's advice on any
matter relevant to an audit, inspection, or other inquiry. We may send information to members of Congress if you ask them to
help you with federal student aid or Student Financial Assistance Programs account(s) questions. Disclosures may be made to
our contractors for the purpose of performing any programmatic function that requires disclosure of records. As part of such a
contract, we will require the contractor to maintain safeguards to protect the security and confidentiality of the records that
are disclosed to the contractor. If a record is relevant and necessary to a borrower complaint regarding participants in any
Federal Student Financial Assistance Programs under title IV of the HEA, ED may disclose a record only during the course of
processing, reviewing, investigating, fact-finding, or adjudicating the complaint to: any party to the complaint; the party's
counsel or representative; a witness; or a designated fact-finder, mediator, or other person designated to resolve issues or
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decide the matter. ED also may disclose records to the DOJ or Office of Management and Budget (OMB) if ED concludes
that disclosure is desirable or necessary in determining whether particular records are required to be disclosed under the
Freedom of Information Act (FOIA) or the Privacy Act. ED may disclose your information to appropriate agencies, entities,
and persons when ED suspects or has confirmed that there has been a breach of the system maintaining your information;
which poses a risk of harm to individuals, ED (including its information systems, programs, and operation), the Federal
agencies, or national security and the disclosure made to such agencies, entities, and persons is reasonably necessary to assist
ED's efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm. ED also may
disclose your information to another Federal agency or Federal entity, when ED determines that your information is
reasonably necessary to assist the recipient agency or entity in responding to a suspected or confirmed breach or preventing,
minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its information systems,
programs, and operations), the Federal agencies, or national security, resulting from a suspected or confirmed breach.

PAPERWORK REDUCTION ACT

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 1845-0132.
Public reporting burden for this collection of information is estimated to average 1 hour 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 a benefit (20 U.S.C.
1087e(h)). If you have comments or concerns regarding the status of your individual submission of this application, please
contact BorrowerDefense@ed.gov directly.

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