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SECTION 4: BORROWER’S UNTAXED ASSISTANCE PAYMENTS INFORMATION

Provide the following information about the untaxed assistance payments you are currently receiving. Untaxed assistance payments include, but are not limited to,

welfare benefits, Social Security benefits, Supplemental Security Income, workers’ compensation, and child support. If you do not have any untaxed assistance

payments, do not fill out this section.

(1) For “Amount of Assistance Payments”, include the total amount(s) of any untaxed assistance payments you receive from all sources. If you have more

than one source of untaxed assistance payments, enter each individual amount in “First Source,” “Second Source,” and “Third Source,” respectively. If

you need additional space, attach a separate piece of paper.

•

For example, if you receive $200 per month in Social Security benefits and $150 per month in workers’ compensation, then report assistance

payments of $200 per month in “First Source” and $150 per month in “Second Source”.

(2) Indicate how often you receive the assistance payment that is supported by the documentation you provide.

Weekly

Amount of Assistance Payment (First Source):

_______________________

Monthly

Other:

___________________________

Weekly

Amount of Assistance Payment (Second Source):

________________________

Monthly

Other:

___________________________

Weekly

Amount of Assistance Payment (Third Source):

________________________

Monthly

Other:

___________________________

You must attach supporting documentation for each source of your assistance payments. Documentation of your assistance payments may include copies

of benefits checks or a letter from a court, a governmental body, or the individual paying alimony or child support specifying the amount. If you do not have

documentation of your assistance payments, attach a signed statement explaining your assistance payment source(s) and giving the address of each source.

Documentation must be dated within 90 days of the date you signed this form.

SECTION 5: SPOUSAL IDENTIFICATION

Only fill out this section if:

(1) you are married and your spouse has taxable income, untaxed assistance payments, or both

(2) at least one of the defaulted loans you want to rehabilitate is a joint consolidation loan.

Provide the following information about your spouse if applicable:

Middle

Last Name

First Name

Social Security Number

Date of Birth (mm-dd-yyyy)

Initial

SECTION 6: SPOUSE’S TAXABLE INCOME INFORMATION – To be completed if you completed SECTION 5.

Provide the following information about your spouse’s taxable income he or she is currently receiving, using the instructions provided in Section 3 of this form.

You must attach supporting documentation for each source of your spouse’s income consistent with the instructions in Section 3.

Weekly (52 times per year)

Amount of Taxable Income (First Source):

_______________________

Every two weeks (26 times per year)

Other:

___________________________

Weekly (52 times per year)

Amount of Taxable Income (Second Source):

________________________

Every two weeks (26 times per year)

Other: