Income-Driven Repayment Plan Request Form - U.s. Department Of Education

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OMB No.1845-0102
Form Approved
Income-Based Repayment (IBR), Pay As You Earn, and Income-Contingent
Exp. Date 11/30/2015
Repayment (ICR) plans for the William D. Ford Federal Direct Loan (Direct Loan)
Program and Federal Family Education Loan (FFEL) Program
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.
Please enter or correct the following information.
Check this box if any of your information has changed.
City, State, Zip Code
Telephone – Primary
Telephone – Alternate
E-mail (optional)
Before completing this form, carefully read the entire form. Return the completed form and any required
documentation to the address shown in Section 7. You may be able to complete your request online by visiting
Other repayment plans may be available and may offer a lower monthly payment amount. You may pay more interest
over time under an income-driven plan and may have to pay federal income tax on any loan amount forgiven under an
income-driven plan. A calculator is available at
to estimate your payment amounts
under all available repayment plans.
1. Please select the reason that you are completing this request by checking box a, b, or c, below.
I am requesting a repayment plan based on my income – Check the plan(s) you are requesting below and
then continue to item 2.
Direct Loan
Income-Driven Repayment Plan
Program Loans
Program Loans
Pay As You Earn
Not Available
Not Available
I request that my loan holder determine which of
the above plans I am eligible for, and place me on
Only IBR is available for FFEL
the plan with the lowest monthly payment amount.
Program loans
Your request will apply to all of your loans that are eligible for the plan you choose. You will need to choose a
different repayment plan for loans that are not eligible for an income-driven repayment plan (see section 9)
or those loans will be placed on the standard repayment plan.
I am submitting annual documentation for the recalculation of my monthly payment amount under my
current repayment plan – Continue to item 2.
I am requesting that my loan holder recalculate my current monthly payment amount because my
circumstances have changed – Continue to item 2.
Check this box if you owe eligible loans to more than one loan holder. You must submit a separate request to
each holder of the loans you want to repay under the IBR, Pay As You Earn, or ICR plan.
You must promptly submit to your loan holder this completed form and a copy of your most recent federal income
tax return or federal income tax return transcript (see Section 4), or, if applicable, alternative documentation of your
current income (see Section 5).
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