Request For Reimbursement Due To Partial Discharge Of A Federal Consolidation Loan

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REQUEST FOR REIMBURSEMENT DUE TO PARTIAL DISCHARGE
OF A FEDERAL CONSOLIDATION LOAN
(TO BE COMPLETED BY LOAN HOLDER/SERVICER)
Section I: DISCHARGE INFORMATION
1. Reason Type:
_____Closed School (CS)
_____Death (DE)
_____Disability (DI) _____False Certification (FC)
2. DCO: _____________________________________
Section II: BORROWER / CO-MAKER / DEPENDENT STUDENT INFORMATION
3. Borrower Name: _____________________________________________________________________ SSN:___________________________
4. Co-Maker Name: ____________________________________________________________________ SSN:___________________________
5. Dependent Student Name: _____________________________________________________________ SSN:___________________________
Section III: FEDERAL CONSOLIDATION LOAN INFORMATION
6. Loan ID
7. 1st Disb Date
8. Principal
9. Interest Rate/Type
_________________________
_________________________
$________________________
___________ / ____________
_________________________
_________________________
$________________________
___________ / ____________
_________________________
_________________________
$________________________
___________ / ____________
Total: $___________________
10. Proration Rate ______________________________%
Section IV: UNDERLYING INFORMATION
11. Loan Type
12. 1st Disb Date
11. Loan Type (cont)
12. 1st Disb Date (cont)
a. _______________________
a. _______________________
e. _______________________
e. _______________________
b. _______________________
b. _______________________
f. _______________________
f. _______________________
c. _______________________
c. _______________________
g. _______________________
g. _______________________
d. _______________________
d. _______________________
h. _______________________
h. _______________________
Section V: AMOUNT REQUESTED
13. Amount Requested: (Multiply total of #8 by #10)
$_________________________________
14. Int-Paid-Through Dt: ____________________________
15. Int Claimed as of: ___________________________
+ $_________________________________
16. Total Amount Requested:
= $_________________________________
17. Eligible Payments:
+ $_________________________________
18. Reimbursement Amount Requested:
$_________________________________
Section VI: LENDER INFORMATION
BY SUBMITTING THIS DOCUMENT TO THE GUARANTOR, THE LENDER/HOLDER CERTIFIES, TO THE BEST OF ITS
KNOWLEDGE, THE INFORMATION IN THIS DOCUMENT IS TRUE AND ACCURATE.
19. Lender ID: _______________________
20. Servicer ID: _______________________
21. Lender/Servicer Name/Address:__________________________________________________________________________________________
22. Prepared by:__________________________________ 23. Preparer’s # (______) _________________________________________________
Required Documentation:
Closed School (CS) = School Closure Loan Discharge Application
Death (DE) = Original or Certified Copy of Death Certificate
Disability (DI) = Copy of the Department of Education’s official notification that the disability
discharge application has been approved
False Certification (FC) = False Certification Loan Discharge Application
1403-59134
04/14

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