Loan Discharge Application Forgery - US Department Of .

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LOAN DISCHARGE APPLICATION: FORGERYOMB No. 1845-0148Form ApprovedExp. Date 10/31/2020William D. Ford Federal Direct Loan (Direct Loan) Program / Federal FamilyEducation Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan) ProgramFFEL Program and Perkins Loan Program: You can use this form to apply for discharge of a FFEL Programor Perkins Loan Program loan only if the loan is held by the U.S. Department of Education.FORGWARNING: Any person who knowingly makes a false statement or misrepresentation on this form or onany accompanying document is subject to penalties that may include fines, imprisonment, or both, underthe U.S. Criminal Code and 20 U.S.C. 1097.SECTION 1: APPLICANT INFORMATIONPlease enter or correct the following information.Check this box if any of your information has changed.SSNNameAddressStateCityZip CodeTelephone - PrimaryTelephone - AlternateEmail (Optional)SECTION 2: DECLARATIONSUse this form if you believe you are the victim of forgery. A definition of forgery can be found in Section 6.4. Did you sign a promissory note, in ink or electronically,for the loans that you want discharged?Yes - You are not eligible for this type of discharge.1. Below, list all loans you want discharged. List onlyloans held by the U.S. Department of Education (theDepartment). To find information about your loans,visit StudentAid.gov/login or call 800-4-FED-AID.Attach additional pages, if necessary.AmountYear Rec'dNo.5. Do you believe the person who borrowed the loansyou want discharged was an employee or affiliate ofthe school that originated or certified the loans?Yes - Complete the Loan Discharge Application forFalse Certification based on UnauthorizedSignature or Payment instead of this form.No.School2. Did you intend to borrow the loans that you wantdischarged?Yes - You are not eligible for this type of discharge.No.3. Did you (or the student), receive a refund in cash,check, or electronic funds transfer from the loans,were the loans applied to your (or the student's)account at a school that you attended, or did you (orthe student) benefit from the loans in any other way?Yes.Don't Know.6. Have you (or the student) attended postsecondaryschool?Yes.No.7. If you (or the student) attended a postsecondaryschool, provide the names, dates of attendance, andwhether the program was an online program:SchoolExplain how you benefited from the loans youwant discharged.No.Page 1 of 7DatesOnline

Applicant NameApplicant SSNSECTION 2: DECLARATIONS (CONTINUED)8. How did you (or the student) pay for the costs ofattendance, such as tuition and fees, at the schoollisted in Item 7? Attach documentation (for example,from the school’s financial records such as receiptsfrom the school, negotiated personal checks, etc.) toshow how you paid for the costs of attendance.13. Which personal information was used without yourpermission? Check any that apply.NameSocial Security NumberDate of BirthAddressTelephone NumberSignatureOther (identify):Don't Know.14. On which documents was your personal informationused without your permission? Check any that apply.Loan check9. Provide your address and dates of residence from theperiod of time when the loans you want dischargedwere originated or certified:AddressLoan application or promissory noteMaster check or electronic funds transferauthorizationOther (identify):Dates of ResidenceDon't Know.15. What documentation are you providing to supportyour claim?Samples of my signature - We require that youprovide four signature samples that appear onactual documents that you signed. Two of thesesamples must be dated one year before or afterthe date the disputed document was signed.Examples of documents include cancelled checks,tax returns, Driver's License, etc.A court verdict or judgment that determined I wasthe victim of the crime of identity theft or forgeryand a copy of information or the indictment thatthe verdict or judgment was based onA government identification card,

of your Direct Loans is the Department. The holder of your FFEL Program loans may be a lender, guaranty agency, secondary market, or the Department. The holder of your Perkins Loans is an institution of higher education or the Department. Your loan holder may use a servicer to handle billing and other communications related to your loans.

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