Total And Permanent Disability Discharge

OMB No. 1845- ‐0065Fo rm Ap pro vedExp. Date 6/30/2016DISCHARGE APPLICATION: TOTAL AND PERMANENT DISABILITYWilliam D. Ford Federal Direct Loan,Federal FamilyEducationLoan,Federal Perkins Loan,and TEACH Grant ProgramsWARNING: Any personwhoknowingly makes a false statement or misrepresentationon this form or o any accompanyingdocuments will be subject topenalties that may include fines, imprisonment, or both, under the U.S. CriminalCode and20 U.S.C. 1097.SECTION 1: APPLICANTIDENTIFICATIONPleaseenter or correct thefollowinginformation.Check this box if any of your information has changed.SSN- ‐- ‐DOB- ‐- ‐NameAddressCity, State, ZipCodeTelephone ()E- ‐mail Address (Optional)SECTION 2: INSTRUCTIONSFOR COMPLETING AND SUBMITTING THISAPPLICATION Carefully readthe entire application, including page 1, the instructions in this section, and the additional information on the following pages. Type or print in dark ink. Sign and date the application in Section 3. If you are required to have physician complete Section 4, enter your name andSocial Security Number at the top of page 2 (if not preprinted). Send the completed application withanyrequired documentation to:U.S. Department of Education, TPD Servicing, PO Box 87130,Lincoln, NE 68501- ‐71301. Are youa veteranwhohas receiveda determinationfrom the U.S. Department of Veterans Affairs (VA) thatyou are unemployable due toa service- ‐connecteddisability?Yes – Attach documentation ofthe VA determination and completeSection 3.You are not requiredtohave a physiciancomplete Section4.No – Continue toItem 2.2. Have you received an SSA notice of award for SSDI or SSI benefits or an SSA Benefits Planning Query (BPQY) statingthat yournext scheduled disabilityreview will be 5 to 7 years or more from the date of your last SSA disability determination?Yes – Attach a copy ofthe SSA notice ofaward or BPQY and completeSection 3.You are not requiredtohave a physician complete Section 4.No – Complete Section3 andhave a physicianwhois a doctor of medicine or osteopathy complete and signSection4. You must submit thisapplicationtous within 90 days of the date of your physician’s signature inSection4.SECTION 3: APPLICANT’SDISCHARGEREQUEST, AUTHORIZATION, UNDERSTANDINGS, AND CERTIFICATIONSI request thatthe U.S. Department of Education discharge my Direct Loan, FFEL, and/or Perkins Loan, program loan(s), and/or my TEACH Grant serviceobligation.I authorize any physician, hospital, or other institution havingrecords about thedisability that is thebasis for my request for a discharge tomakeinformation from those records available to the U.S. Department of Education.I understand that:(1)If I am applying for discharge based on a physician’s certification in Section 4, I must submit this application to the U.S. Department of Educationwithin90 days of thedateof my physician’s signaturein Section 4.(2)Unless I am a veteran who provides thedocumentation described abovein Section 2, Item 1, I may be required to repay a discharged loan or satisfy adischargedTEACH Grant service obligationif I fail tomeet certainrequirements during a post- ‐discharge monitoring period, as explained in Section 6.(3)If I am a veteran who does not meet the requirement describedabove inSection2, Item 1, andI have obtained a certification from a physician inSection 4, the certification by the physicianon this form is only for the purposes of establishing my eligibility toreceive a discharge of a Direct LoanProgram loan, a FFEL Program Loan, a Perkins Loan Program loan, and/or a TEACH Grant serviceobligation, and is not for purposes of determining myeligibilityfor, or theextent of myeligibilityfor, VA benefits.(4)If I wish to designate an individual or organization to represent me in matters related to my total and permanent disability dischargerequest, I mustcomplete and submit the Total and Permanent Disability Discharge: Applicant RepresentativeDesignation form.I certify that: (1) I have a totaland permanent disability, as defined in Section 5;and (2) I have read and understand the information on the dischargeprocess, the terms andconditions for discharge, andthe eligibility requirements toreceive future loans or TEACH Grants as explained in Sections 6 and 7.Signature of Applicant orApplicant’s Representative (see NOTE below)DatePrinted Nameof Representative(if applicable)NOTE: You may designate anindividual or organizationtorepresent youinmatters relatedtoyour total andpermanent disability discharge request.Ifyouwish to designate a representative,you must complete the Total and Permanent Disability:Applicant Representative Designation form. You may obtain thisform from our Total and Permanent Disability Discharge Servicer.See the “Read This First” section ofthis form forcontact information.Page2of7

Applicant Name:Applicant SSN:- ‐- ‐SECTION 4: PHYSICIAN’SCERTIFICATIONInformation and Instructions for Physician: The applicant identified above is applying for discharge of federal student loan and/or a teaching service obligation fora federal granton the basis thatheor she has a total andpermanent disability, as definedinSection5 of this form. Toqualify for a discharge, the applicant must be unable toengagein anysubstantial gainful activity(asdefined below andin Section 5) by reason of a medically determinable physicalormentalimpairment that (1) can be expectedto resultin death; or (2) has lastedfor a continuous periodof not less than60 months; or (3) can be expected to last for a continuousperiod of not lessthan60 months. This disability standard may be different from standards used under other programs in connection with occupational disability,or eligibility forsocial service or veterans benefits. A determination that theapplicant is disabled byanother federal agency(for example, theSocial SecurityAdministration)or a state agency does not automatically establish theapplicant’s eligibilityfor this loan discharge. Complete this form only ifyou are a doctorofmedicine orosteopathy legally authorized to practice in a state, as defined in Section 5, andonly if theapplicant’s condition meets thedefinition of total and permanent disability in Section 5. Print legibly in dark ink or type.All fields mustbe completed.If a field is not applicable,enter “N/A.” Your signature date must include month, day, andyear(mm- ‐dd- ‐yyyy). Provideall requested information for Items 1, 2, and 3 below, and attach additional pages if necessary. Complete the physician’s certificationat the bottom ofthis page.The applicant’s loan discharge application cannot be processed if the information requested in this section is missing or if your signature is missing. If you make any changes to the information you provide in this section, you must initialeach change. Pleasereturn thecompleted form to theapplicant or theapplicant’s representative. The U.S. Department of Education may contact you for additionalinformationor documentation.1. Medically Determinable Physical or Mental Impairment. Does the applicant have a medically determinable physical or mental impairment that(a) preventsthe applicantfrom engaging in any substantial gainful activity, in any field ofwork,and (b) can be expected to result in death, or has lastedfor a continuousperiodof not less than60 months, or can be expected to last for a continuousperiod of not less than 60 months?YesNoSubstantial gainful activitymeans a level of work performed for pay or profit that involves doing significant physical or mental activities, or a combination ofboth. If the applicant is able to engage in any substantialgainfulactivity, in any field of work, you must answer “No.” The determinationof whether or not theapplicant canperform substantial gainful activity is not basedon whether the applicant canperform his or her current or past jobor profession.IF THE ANSWER TO QUESTION 1 IS NO,DO NOT COMPLETETHIS APPLICATION.2. DisablingCondition. Complete Items (a) and (b) regarding the applicant’s disabling impairment.Do not use abbreviations or insurance codes.(a)Provideyour diagnosis of the applicant’s impairment:(b)Describe the severity of the disabling physical or mental impairment, including, if applicable, thephaseof thedisablingcondition:3. Limitations. Explain how the disabling condition prevents the applicant from engaging in substantial gainful activity in any field ofwork by responding to Items(a) through (e) below, as relevant tothe applicant’s condition. Attachadditional pages if more space is needed.In addition to what is required below, you may include any additionalinformation that you believe would be helpfulin understanding the applicant’scondition, such as medications used to treat the condition, surgicaland non- ‐surgical treatmentsfor the condition, etc.(a) Limitations on sitting, standing, walking, or lifting:(b) Limitations on activities of daily living:(c)Residual functionality:(d) Social/behavioral limitations, if any:(e) Current Global Assessment FunctionScore (for psychiatric conditions):Physician’s Certification I certify that, in my bestprofessional judgment, the applicantidentified above is unable to engage in any substantial gainful activityin any field ofwork byreason ofa medically determinable physicalormentalimpairmentthat(1) can be expected to result in death;or (2) has lastedfor a continuous periodof notless than 60 months; or (3) can be expected to last for a continuousperiod of not lessthan 60 months. I understand thatan applicantwho is currently able to engage in any substantial gainful activityin any field ofwork does nothave a total and permanentdisability as definedon this form.I am a doctor of (check one)medicineosteopathy/osteopathic medicine.I am legally authorized to practice in the state identified below andI have providedmy professional license number below.State Where Legally Authorized to PracticeProfessional LicenseNumber(stamp isacceptable; subject to verification through state records)Physician’s Signature(a signaturestamp is not acceptable)Date (mm- ‐dd- ‐yyyy)Address (stamp is acceptable)()TelephonePrinted Nameof Physician (first name, middle initial, last name)City, State, ZipCode()FaxE- ‐mail Address (Optional)Page3of7

SECTION 5: DEFINITIONS! If you have a total and permanent disability, this means that:(1)You are unable to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that can beexpectedto resultin death, or thathas lasted fora continuous period ofnotless than 60 months, orthatcan be expectedtolast for a continuous periodof notless than 60 months;OR(2) You are vetera

Federal Perkins Loan Program TEACH Grant Program. READ THIS FIRST This is an application for a total and permanent disability dischargeof your William D. Ford Federal Direct Loan (Direct Loan) Program, Federal Family Education Loan (FFEL) Program, and/or Federal Perkins Loan (Perkin