1845 0120 – Fill Out and Use This PDF

LOAN REHABILITATION: INCOME AND EXPENSE

OMB No. 1845-0120

INFORMATION

Form Approved

Exp. Date 06/30/2023

Name

Address

City

State

Zip Code

Telephone - Primary

Telephone - Alternate

Email (Optional)

MONTHLY INCOME

MONTHLY EXPENSES

Borrower Name

Borrower SSN

SECTION 3: FAMILY SIZE AND SPOUSE IDENTIFICATION

Borrower's Signature

Date

Date

Spouse's Signature

If you are not completing this form electronically, type or

Basic communication: Include the amount spent on

print using dark ink. Enter dates as month-day-year (mm-dd-

basic communication expenses, such as basic telephone,

yyyy). Use only numbers. Example: March 14, 2017 =

internet, and cable TV.

03-14-2017. Include your name and the account numbers for

Medical and dental: Include the amount spent on

your defaulted loans on any documentation that you are

required to submit with this form. If you need help

necessary medical and dental expenses and procedures not

completing this form, contact your loan holder.

covered by insurance, such as medically necessary

Return the completed form to the address shown in

prescription and nonprescription medications, and

medically necessary nutritional supplements. Do not include

Section 8

any costs relating to medical or dental insurance premium

MONTHLY INCOME IN SECTION 2 (ITEMS 1-9)

payments.

The William D. Ford Federal Direct Loan (Direct Loan)

Reasonable and affordable payment amount means a

Program includes Federal Direct Stafford/Ford (Direct

monthly payment determined by the loan holder based

Subsidized) Loans, Federal Direct Unsubsidized Stafford/

either on the 15% formula or on information provided in this

Ford (Direct Unsubsidized) Loans, Federal Direct PLUS

form and supporting documentation. It cannot be a

(Direct PLUS) Loans, and Federal Direct Consolidation (Direct

percentage of your total loan balance or based on

Consolidation) Loans.

information unrelated to your total financial circumstances.

The Federal Family Education Loan (FFEL) Program

The 15% formula means 15% of the amount by which

includes Federal Stafford Loans (both subsidized and

your Adjusted Gross Income exceeds 150% of the poverty

unsubsidized), Federal PLUS Loans, Federal Consolidation

guideline amount that is applicable to your family size and

Loans, and Federal Supplemental Loans for Students (SLS).

state, divided by 12. Your minimum payment may not be

Rehabilitation of your defaulted loan occurs only after

less than $5.00.

you have made 9 voluntary, reasonable and affordable

monthly payments within 20 days of the due date during 10

The loan holder of a defaulted Direct Loan Program

consecutive months and, for FFEL loans held by a guaranty

loan is the Department. The loan holder of a defaulted FFEL

agency, when the loan has been sold to an eligible lender or

Program loan may be a guaranty agency or the Department.

assigned to the U.S. Department of Education (the

Public assistance means payments you receive under a

Department). When you rehabilitate your loans, you will

regain all the benefits of the Direct Loan Program or FFEL

federal or state program. These assistance programs include,

Program, including eligibility for deferments or forbearances

but are not limited to, Temporary Assistance for Needy

and for a repayment plan with a monthly payment amount

Families (TANF), Supplemental Security Income (SSI), Food

based on your income. You will also regain eligibility to

Stamps/Supplemental Nutritional Assistance Program

receive additional federal student aid, including additional

(SNAP), or state general public assistance.

federal student loans. After a defaulted loan is rehabilitated,

your loan holder will instruct any consumer reporting

agency (credit bureau) to which the default was reported to

remove the default from your credit history.

SECTION 7: LOAN REHABILITATION AGREEMENT

Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C.

To assist program administrators with tracking

552a) requires that the following notice be provided to you:

refunds and cancellations, disclosures may be made to

The authorities for collecting the requested

guaranty agencies, to financial and educational institutions,

or to federal or state agencies. To provide a standardized

information from and about you are §421 et seq. and §451

method for educational institutions to efficiently submit

et seq. of the Higher Education Act of 1965, as amended (20

student enrollment statuses, disclosures may be made to

U.S.C. 1071 et seq. and 20 U.S.C. 1087a et seq.) and the

guaranty agencies or to financial and educational

authorities for collecting and using your Social Security

institutions. To counsel you in repayment efforts, disclosures

Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20

may be made to guaranty agencies, to financial and

U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b).

educational institutions, or to federal, state, or local

Participating in the William D. Ford Federal Direct Loan

agencies.

(Direct Loan) Program or the Federal Family Education Loan

(FFEL) Program and giving us your SSN are voluntary, but

In the event of litigation, we may send records to the

you must provide the requested information, including your

Department of Justice, a court, adjudicative body, counsel,

SSN, to participate.

party, or witness if the disclosure is relevant and necessary

The principal purposes for collecting the

to the litigation. If this information, either alone or with

other information, indicates a potential violation of law, we

information on this form, including your SSN, are to verify

may send it to the appropriate authority for action. We may

your identity, to determine your eligibility to receive a loan

send information to members of Congress if you ask them

or a benefit on a loan (such as a deferment, forbearance,

to help you with federal student aid questions. In

discharge, or forgiveness) under the Direct Loan and/or

circumstances involving employment complaints,

FFEL Programs, to permit the servicing of your loans, and, if

grievances, or disciplinary actions, we may disclose relevant

it becomes necessary, to locate you and to collect and

records to adjudicate or investigate the issues. If provided

report on your loans if your loans become delinquent or

for by a collective bargaining agreement, we may disclose

default. We also use your SSN as an account identifier and to

records to a labor organization recognized under 5 U.S.C.

permit you to access your account information

Chapter 71. Disclosures may be made to our contractors for

electronically.

the purpose of performing any programmatic function that

The information in your file may be disclosed, on a

requires disclosure of records. Before making any such

case-by-case basis or under a computer matching program,

disclosure, we will require the contractor to maintain Privacy

to third parties as authorized under routine uses in the

Act safeguards. Disclosures may also be made to qualified

appropriate systems of records notices. The routine uses of

researchers under Privacy Act safeguards.

this information include, but are not limited to, its disclosure

Paperwork Reduction Notice. According to the

to federal, state, or local agencies, to private parties such as

Paperwork Reduction Act of 1995, no persons are required

relatives, present and former employers, business and

to respond to a collection of information unless such

personal associates, to consumer reporting agencies, to

collection displays a valid OMB control number. The valid

financial and educational institutions, and to guaranty

OMB control number for this information collection is

agencies in order to verify your identity, to determine your

1845-0120. Public reporting burden for this collection of

eligibility to receive a loan or a benefit on a loan, to permit

information is estimated to average 60 minutes per

the servicing or collection of your loans, to enforce the

response, including time for reviewing instructions,

terms of the loans, to investigate possible fraud and to verify

searching existing data sources, gathering and maintaining

compliance with federal student financial aid program

the data needed, and completing and reviewing the

regulations, or to locate you if you become delinquent in

collection of information. The obligation to respond to this

your loan payments or if you default. To provide default rate

collection is required to obtain a benefit in accordance with

calculations, disclosures may be made to guaranty agencies,

34 CFR 682.405 or 685.211. If you have questions regarding

to financial and educational institutions, or to state

the status of your individual submission of this form, contact

agencies. To provide financial aid history information,

your loan holder (see Section 8).

disclosures may be made to educational institutions.