Loan Discharge Application: School Closure (Page 2 of 5) in pdf

Borrower Name: ______________________________ Borrower SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 2: SCHOOL CLOSURE INFORMATION (CONTINUED)

16. Did the holder of your loan receive any money back (a

20. Provide the following about the party with whom the

refund) from the closed school on your behalf?

claim was made or from whom payment was received:

Yes – Continue to Items 17– 19.

a. Name: ___________________________________

No – Skip to Item 19.

b. Address (street, city, state, zip code):

Don’t Know – Skip to Item 19.

_________________________________________

17. What was the amount of the refund?

c. Telephone number:

$___________________________________________

( _______ ) _______ - _____________

18. Explain why the money was refunded:

____________________________________________

21. What is the amount and the status of the claim?

____________________________________________

a. Amount: $________________________________

____________________________________________

b. Status:

19. Did you (or, for a parent PLUS borrower, the student)

_________________________________________

make any monetary claim with, or receive any

_________________________________________

payment from, the closed school or any third party

_________________________________________

(see definition in Section 5) in connection with

22. What was the amount of any payment received? If

enrollment or attendance at the school?

none, write “none”.

Yes – Continue to Items 20 – 22.

$___________________________________________

No – Sign and date the form in Section 3. Submit

the form to the loan holder in Section 7.

Sign and date the form in Section 3. Submit the form to

Don’t Know – Sign and date the form in Section 3.

the loan holder in Section 7.

Submit the form to the loan holder in Section 7.

SECTION 3: BORROWER CERTIFICATIONS, ASSIGNMENT, AND AUTHORIZATION

I certify that: (1) I received the Direct Loan, FFEL, or Perkins Loan Program loan funds directly, or as a credit that was

applied to the amount owed to the school; (2) I (or, if I am a parent PLUS borrower, the student) was enrolled at the

school identified in Section 2, was on an approved leave of absence on the date that the school closed, withdrew

from the school not more than 120 days before it closed, or withdrew from the school more than 120 days before it

closed if the Department determines that exceptional circumstances related to the school’s closing justify an

extension of this 120-day period (see Section 6); (3) Due to school closure, I (or, if I am a parent PLUS borrower, the

student) did not complete the program of study at the closed school; (4) I (or, if I am a parent PLUS borrower, the

student) did not complete and am not in the process of completing the program or a comparable program of study

at the closed school at another school through a teach-out, by transferring credits or hours earned at the closed

school to another school, or by any other comparable means; (5) I have read and agree to the terms and conditions

for loan discharge, as specified in Section 6; (6) Under penalty of perjury, all of the information I have provided on

this form and in any accompanying documentation is true and accurate to the best of my knowledge and belief.

I hereby assign and transfer to the U.S. Department of Education (the Department) any right to a refund on the

amount discharged that I may have received from the school identified in Section 2 of this form and/or any owners,

affiliates, or assignees of the school, and from any third party that may pay claims for a refund because of the

actions of the school, up to the amount discharged by the Department on my loan(s).

I authorize the loan holder to which I submit this request (and its agents or 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 ___ ___ - ___ ___ - ___ ___ ___ ___

Page 2 of 5

Loan Discharge Application: School Closure Page 2

Related Articles

Related forms

Related Categories