Loan Discharge Applications (DL/FFEL/Perkins)

	LOAN DISCHARGE APPLICATION: UNPAID REFUND William D. Ford Federal Direct Loan (Direct Loan) Program Federal Family Education Loan (FFEL) Program	OMB No. 1845-0058 Form Approved Exp. Date 12/31/2026
	WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on 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.

SECTION 1: BORROWER IDENTIFICATION

	Please enter or correct the following information. Check this box if any of your information has changed.
SSN
Name
Address
City		State			Zip Code
Telephone – Primary
Telephone – Alternate
Email (Optional)

BEFORE YOU BEGIN

Carefully read the entire application before completing it. Complete each item in Section 2 unless the item is identified as optional or the instructions tell you skip an item.

If the school is still open, contact the school and attempt to resolve the issue before applying for discharge.

If the school has closed and you were enrolled when the school closed, you may be eligible for a closed school discharge. If you are unsure about whether an unpaid refund or closed school discharge is most appropriate for you, contact your loan holder (see Section 8).

SECTION 2: SCHOOL AND LOAN INFORMATION

1. You are applying for this loan discharge as a:

Student borrower - Skip to Item 4.

Parent PLUS borrower - Continue to Item 2. If a question includes "(or the student)," answer as it applies to the student on whose behalf you borrowed the loan.

2. Student Name (Last, First, MI):

______________________________________________

3. Student SSN: ___________________________________

4. School Name: ___________________________________

School Address (Street, City, State, Zip Code):

5. Are you (or the student) still attending this school?

Yes – You are not eligible for this discharge.

No

6. Do you (or the student) have any other pending or approved discharge applications for loans you received to attend this school?

Yes – Skip to Item 8.

No

7. Have you (or the student) requested or received a refund or payment from the school or any third party (see Section 6) for any loan that you are requesting be discharged?

Yes

No – Skip to Section 3.

For Items 8-10, attach additional pages if you need to report additional discharges, refunds, or payments.

8. Reason you (or the student) requested the discharge, refund, or payment:

Borrower Name ____________________________________________________ Borrower SSN _____________________________

SECTION 2: SCHOOL AND LOAN INFORMATION (CONTINUED)

9. Provide the name and telephone number of the person or organization you (or the student) received the discharge, refund, or payment from:

Name: _________________________________________

Telephone number: ______________________________

10. Amount you (or the student) received or that you expect to receive:

____________________________________

SECTION 3: REFUND INFORMATION

If you are unable to provide any of the information requested in this section, write “Don't Know.” Attach a copy of any documentation that supports your responses to Items 13 through 17. Examples of documentation may include the school's catalog or refund policy, tuition bills, enrollment contracts, student account statements, registration forms, withdrawal forms, attendance records, or any correspondence from the school that contains information about the refund you believe the school owes you.

11. Do you have documentation from the school showing the amount of the unpaid refund?

Yes – Attach the documentation.

No - Skip to Item 13.

12. Do you believe that the amount of the refund shown in the documentation is correct?

Yes – Skip the remaining items in this section. Sign and date the application in Section 4, then send it and any documentation to the address in Section 8.

No

Don't Know

13. What amount do you believe the school owes you?

______________________________________________

14. Why do you believe the school owes you this amount?

    
    
    

    
    
    

    
    

15. Dates that you (or the student) attended the school:

    First Date: ____________	OR	Never Attended
    Last Date: ____________		Don’t Know

16. Enter the name of the program of study that you (or the student) were enrolled in at the school:

______________________________________________

17. Enter the total amount of the federal grants and loans received for any part of the period of enrollment you received the loan for: _____________________________

Sign and date the form in Section 4, then send it and any documentation to the address in Section 8.

SECTION 4: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION

I certify that:

• I (or the student) directly received the loan funds I am requesting be discharged, or they were applied as a credit to my or to the student's school account to pay the amount owed to the school.

• I (or the student) did not attend the school, withdrew from the school, or was terminated from the school within a time frame that meant I should have received a refund of some or all of the loan funds.

• Except as indicated in Section 2, Items 6 through 10, I have not received this refund, or any benefit of a refund I should have received, from the school or any third party (see Section 6).

• I have read and agree to the terms and conditions for loan discharge, as specified in Section 7.

• Under penalty of perjury, all of the information I have provided on this application and in any accompanying documentation is true and accurate to the best of my knowledge and belief.

By signing this application, I assign and transfer to the U.S. Department of Education (the Department) any right I have to a refund on the amount discharged from the school and/or from any owners, affiliates, or assignees of the school, and from any third party that pays claims for a refund because of the actions of the school.

I authorize the organization I submit this request to and its agents to contact me regarding my request or my loans at the cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or prerecorded voice or text messages.

Borrower's Signature _________________________________________________ Date ______________________________

SECTION 5: INSTRUCTIONS FOR COMPLETING THE APPLICATION

When completing this application, type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only numbers. Example: March 14, 2024 = 03-14-2024. If you need more space to answer any of the items, continue on separate sheets of paper and attach them to this application. Identify the question number for which you are providing additional information. Include your name and Social Security Number (SSN) at the top of page 2 and on all attached pages. Return the completed application and documentation to the address shown in Section 8.

SECTION 6: DEFINITIONS

The William D. Ford Federal Direct Loan (Direct Loan) Program includes Federal Direct Stafford/Ford (Direct Subsidized) Loans, Federal Direct Unsubsidized Stafford/Ford (Direct Unsubsidized) Loans, Federal Direct PLUS (Direct PLUS) Loans, and Federal Direct Consolidation (Direct Consolidation) Loans.

The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans (both subsidized and unsubsidized), Federal Supplemental Loans for Students (SLS), Federal PLUS Loans, and Federal Consolidation Loans.

The holder of your Direct Loan Program loans is the Department. The holder of your FFEL Program loans may be a lender, a guaranty agency, or the Department. Your loan holder may use a servicer to handle billing and other communications related to your loans. References to “your loan holder” on this form mean either your loan holder or your servicer.

If your loan is discharged, this means that you (and any endorser) are not required to repay the remaining portion of the loan, and you will be reimbursed for any payments on the loan that you made voluntarily or through forced collection (for example, through wage garnishment or Treasury offset). For a consolidation loan, only the portion that represents the original loans you received and that are eligible for discharge will be discharged. The loan holder reports the discharge to all consumer reporting agencies to which the holder previously reported the status of the loan and requests the removal of any adverse credit history previously associated with the loan.

The student refers to the student on whose behalf the parent borrower obtained a Direct PLUS Loan or Federal PLUS Loan.

Program of study means the instructional program leading to a degree or certificate you (or the student) were enrolled in.

Third party refers to any entity that may provide reimbursement for a refund owed by the school, such as a State or other entity offering a tuition recovery program.

SECTION 7: TERMS AND CONDITIONS FOR LOAN DISCHARGE BASED ON UNPAID REFUND

If the school did not refund a portion of your loan that it was required to refund under applicable law and regulations, you are eligible to have that portion of your loan discharged.

Only loans made on or after January 1, 1986 are eligible for this type of discharge.

By signing this application, you are agreeing to provide, upon request, testimony, a sworn statement, or other documentation reasonably available to you that demonstrates to the satisfaction of the Department or its designee that you meet the qualifications for loan discharge, or that supports any statement you made on this application or in any accompanying documents.

By signing this application, you are agreeing to cooperate with the Department or the Department's designee in any enforcement action related to this application.

Your application may be denied or your discharge may be revoked, if you fail to provide testimony, a sworn statement, or documentation upon request, or if you provide testimony, a sworn statement, or documentation that does not support the statements that you have made on this form or in any accompanying documents.

SECTION 8: WHERE TO SEND THE COMPLETED APPLICATION

Return the completed application and any documentation to: (If no address is shown, return to your loan holder.)

If you need help completing this application, call: (If no telephone number is shown, call your loan holder.)

SECTION 9: IMPORTANT NOTICES

Privacy Act Statement

Authority: The authorities for collecting the requested information from and about you are §421 et seq. and §451 et seq. of the Higher Education Act of 1965, as amended (20 U.S.C. 1071 et seq. and 20 U.S.C. 1087a et seq.), and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b).

Purpose: The principal purposes for collecting the information on the Loan Discharge Application: Unpaid Refund 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 William D. Ford Federal Direct Loan (Direct Loan) and/or Federal Family Education Loan (FFEL) programs, to permit the servicing of your loans, to enforce the conditions or terms of a title IV, HEA obligation, to originate, disburse, service, collect, assign, adjust, transfer, refer, furnish credit information for, and discharge a title IV, HEA obligation, to verify whether a title IV, HEA obligation qualifies for discharge, to determine credit balances to be refunded by the U.S. Department of the Treasury (Treasury) to the individual or loan holder, and, if it becomes necessary, to locate you and to collect and report on your loans if your loans become delinquent or default. We also use your SSN as an account identifier and to permit you to access your account information electronically.

Disclosures: The information provided on the Loan Discharge Application: Unpaid Refund form will only be disclosed outside of the U.S. Department of Education (Department) with prior written consent or as otherwise allowed by the Privacy Act of 1974, as amended (Privacy Act) (5 U.S.C. 552a). One of the exceptions to the Privacy Act’s prior written consent requirement that allows for disclosure, without consent, is for “routine uses” that the Department publishes in our System of Records Notices (SORNs). The Department may disclose, without consent, the information provided on a Loan Discharge Application: Unpaid Refund form, on a case-by-case basis or under a computer matching program, to third parties pursuant to the routine uses identified in the “Common Services for Borrowers (CSB) System” (18-11-16) SORN. This notice is available on the Department’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.

These routine uses included, but are not limited to:

• To verify the identity of the individual who records indicate has applied for or received title IV, HEA program funds, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, Tribal, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; to adjudicative bodies; and to the individual whom the records identify as the party obligated to repay the title IV, HEA obligation;

• To determine program eligibility and benefits, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To enforce the conditions or terms of a title IV, HEA obligation, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; to adjudicative bodies; and to the individual whom the records identify as the party obligated to repay the title IV, HEA obligation;

• To permit originating, disbursing, servicing, collecting, assigning, adjusting, transferring, referring, furnishing of credit information, or discharging title IV, HEA obligations, disclosures may be made to guaranty agencies, educational institutions, or financial institutions that originated, held, serviced, or have been assigned the title IV, HEA obligation, and their authorized representatives; to a party identified by the debtor as willing to advance funds to repay the title IV, HEA obligation; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, business and personal associates, and present and former employers; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To investigate possible fraud or abuse or to verify compliance with contractual requirements or Federal, State, local, or Tribal statutory, regulatory, or program requirements, disclosures may be made to guaranty agencies, educational and financial institutions, third-party servicers, and their authorized representatives; to Federal, State, Tribal, or local agencies, and their authorized representatives; to private parties, such as relatives, present and former employers, and business

SECTION 9: IMPORTANT NOTICES (CONTINUED)

and personal associates; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To locate a delinquent or defaulted borrower, or an individual who owes a title IV, HEA obligation, disclosures may be made to guaranty agencies;

• To verify whether a title IV, HEA obligation qualifies for discharge, disclosures may be made to guaranty agencies, educational and financial institutions, and their authorized representatives; to Federal, State, or local agencies, and their authorized representatives; to private parties, such as relatives, present and former employers, and business and personal associates; to creditors; to consumer reporting agencies; and to adjudicative bodies;

• To prepare a title IV, HEA obligation for litigation, to provide support services for litigation on a title IV, HEA obligation, to litigate a title IV, HEA obligation, or to audit the results of litigation on a title IV, HEA obligation, disclosures may be made to FFEL loan holders or servicers; Department contractors including but not limited to, Federal Loan Servicers, NFP Federal Loan Servicers, the Federal Perkins Servicer, PCAs and to guaranty agencies and their authorized representatives; Federal, State, Tribal, or local agencies, and their authorized representatives; and to adjudicative bodies.

For additional routine uses, view the “Common Services for Borrowers (CSB) System” (18-11-16) SORN. This notice is available on the Department’s “Privacy Act System of Record Notice Issuances (SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.

Consequences of Failure to Provide Information: Participating in the Direct Loan Program or the FFEL Program is voluntary, but providing the Department your SSN and requested information is mandatory to participate.

Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0058. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. The obligation to respond to this collection is required to obtain or retain a benefit (34 CFR 682.402(l)(4), or 685.216(c)).

If you have comments or concerns regarding the status of your individual submission of this form, contact your loan holder(s) (see Section 8) directly.

Page 2 of 7