Financial Disclosure For Reasonable And Affordable Rehabilitation Payments Form - U.s. Department Of Education Page 4

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SECTION 9: REASONABLE AND NECESSARY EXPENSES (CONTINUED)
(6) For “Insurance”, include the amount spent on insurance, such as home (unless you included it in (2) above), renter’s, auto, medical, dental, or life
insurance. Include any amounts paid toward insurance premiums, but do not include any amount that is deducted from your paycheck and reflected in
Sections 3 or 6.
Amount spent on Insurance
(7) For “Transportation”, include the amount spent on basic transportation expenses, such as gas, car loans, basic vehicle maintenance, and public
transportation.
Amount spent on Transportation
(8) For “Dependent Care”, include the amount spent on care for children or other dependents in the household.
Amount spent on Dependent Care
(9) For “Legally Required Child and Spousal Support”, include the amount spent on legally required child care and spousal support.
Amount spent on Legally Required
Child and Spousal Support
(10) For “Student Loans”, include the amount spent on any Federal or private student loan. Include any type of payment, voluntary or otherwise. Do not
include amounts associated with the loan you are trying to rehabilitate, unless you are subject to mandatory withholding such as wage garnishment or
Treasury offset (i.e. your social security is being garnished).
Amount spent on Student Loans
(11) For “Other Expenses”, include the amount spent on any other necessary expense not covered in the prior 10 categories. In the space below (or on a
separate page, if necessary), describe the expense and explain in detail why the expense is necessary. Other Expenses must be approved by the
Department of Education.
Amount spent on Other Expenses
Reasons:
SECTION 10: UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION
 I understand that:
(1) I am submitting this information because I requested, either orally or in writing, that my defaulted Direct Loan or FFEL Loan(s) be rehabilitated.
(2) To rehabilitate my defaulted loan, I must make at least 9 on time (within 20 days of the due date), voluntary, reasonable and affordable monthly payments in a period of 10
consecutive months. If I am a FFEL borrower, my FFEL loan is not rehabilitated until it is sold to an eligible lender after I make the qualifying payments.
(3) When I submit this completed form to my loan holder(s), my loan holder(s) will use the information on the form and any required attached documentation to determine the
reasonable and affordable payment amount. Within 15 business days of that determination, my loan holder(s) will provide me with a written rehabilitation agreement which must
include the reasonable and affordable payment amount that I pay to rehabilitate my loans, unless I object to that amount as described in (5) below.
(4) The monthly reasonable and affordable payment amount must be based solely on the information and supporting documentation I am required to provide in this form—it may
not be based on my total outstanding loan balance or on information unrelated to my total financial circumstances.
(5) I may object orally or in writing to the monthly reasonable and affordable payment amount determined by the loan holder(s).
(6) If I object to the reasonable and affordable payment amount determined by the loan holder(s), my loan holder(s) will recalculate my payment amount using the income-based
repayment formula, which may result in a different reasonable and affordable monthly payment. At this point I may choose which of these two amounts I prefer.
(7) If I successfully rehabilitate my defaulted Direct Loan, the U.S. Department of Education (Department) will instruct any consumer reporting agency to which the default was
reported to remove the default from my credit history. If I successfully rehabilitate my defaulted FFEL loan(s), the Department, guaranty agency, or prior holder of the loan(s)
will request that any consumer reporting agency to which the default was reported remove the record of default from my credit history, but not the delinquent payments leading
up to the default.
(8) If I successfully rehabilitate my loan(s), collection costs may be added to the unpaid principal of the loan, but those collection costs may not exceed 18.5 percent of the unpaid
principal and accrued interest on the loan.
(9) If I hold a defaulted joint consolidation loan, both borrowers must request loan rehabilitation and our signatures below serve as that request.
(10) If I rehabilitate a loan and then default on that loan again, I will not be allowed to rehabilitate that loan a second time.
 I certify that: (1) The information I have provided on this form is true and correct. (2) I will provide additional documentation to my loan holder, as required, to support the
information I have provided in this form. (3) I have read, understand, and meet the eligibility requirements for applying to rehabilitate my loan(s), as explained in Section 1.
 I authorize the entity to which I submit this request (i.e., the guaranty agency, the Department, and their respective agents and contractors) to contact me regarding my request or
my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future number that I provide for my cellular telephone or other wireless device using
automated telephone dialing equipment or artificial or prerecorded voice or text messages.
Borrower’s Signature
Date
Spouse’s Signature
(if you filled out Section 5)
Date
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