Request For Review Form
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1
2REQUEST FOR REVIEW
NAME___________________________________________ SSN__________________________
CURRENT ADDRESS ____________________________________________________________
If you object to offset against your Federal and/or State tax refunds and other payments for the
student loan described in the Loan Statement or notice, you can use this form to request a review or
hearing. If you object ONLY because you believe you cannot afford to pay this debt, but you wish
to arrange payment terms, DO NOT USE THIS FORM. INSTEAD, write or call the Contact listed
on the Loan Statement.
IMPORTANT. You should request and review copies of the records evidencing your loan
before you complete this statement. See the Notice of Proposed Treasury Offset for
instructions on how to request these records.
______________________________________________________________________________
I. Check ONLY ONE of the following:
A.
I want a review of my objection based on this written statement and the records in my loan
file. COMPLETE PARTS II AND IV OF THIS FORM.
B.
I want an in-person hearing in the city shown on the Loan Statement to present my objection.
I understand that I must pay my own expenses to appear for this hearing. COMPLETE PARTS II,
III, AND IV OF THIS FORM. Provide a telephone number where you can be reached during the
day: __________________
C.
I want a hearing by telephone. COMPLETE PARTS II, III, AND IV OF THIS FORM.
Provide a telephone number where you can be reached during the day: ____________________
________________________________________________________________________________
II. Check the objections that apply. ENCLOSE the documents described here (if you do not enclose
documents, your objections will be reviewed, based on the information on this form and the records
in your loan file):
1.
I do not owe the full amount shown because I repaid some or all of this loan. ENCLOSE
copies of front and back of checks, and copies of money orders and receipts for payments made on
the loan.
2.
I am making payments on this loan as required under the repayment agreement I reached with
the holder of the loan. ENCLOSE copies of repayment agreement and front and back of payment
checks.
3.
I filed for bankruptcy and my case is still open. ENCLOSE copies of any court document
showing name of court and case number.
4.
This loan was discharged in bankruptcy. ENCLOSE copies of discharge order and the
schedule of debts filed with the court.
5.
I am totally and permanently disabled and I submitted a completed Discharge Application:
Total and Permanent Disability to the U. S. Department of Education’s Total and permanent
Disability Servicer on ________________________________.
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