1845 0120 PDF Details

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Form Name1845 0120
Form Length5 pages
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesform financial pdf printable, financial disclosure loan, omb 1845 0120, form 1845

Form Preview Example


OMB No. 1845-0120


Form Approved

Exp. Date 06/30/2023

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family

Education Loan (FFEL) Program

RIE 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.


















Zip Code

Telephone - Primary






Telephone - Alternate






Email (Optional)







You received this form because you asked to rehabilitate your defaulted loans, but objected to the payment amount your loan holder calculated using the 15% formula (see Section 6). After receiving this form, your loan holder will offer an alternative payment amount. The alternative amount may be less or more than the amount calculated using the 15% formula. To begin rehabilitating your defaulted loans, you must choose between the two amounts. To rehabilitate, you must make 9 on-time payments of that amount over a period of 10 consecutive months.

Provide the monthly income and expense information listed below. Include documentation of these sources of income or expenses if your loan holder asks you to. Include your spouse's income only if your spouse contributes to your household income. Your loan holder has the authority to determine if the claimed amount of any expense is reasonable and necessary.

Before entering your monthly income and expenses, carefully read the entire form, including Sections 5, 6, and 7.



1.Your employment income

2.Spouse's employment income

3.Child support received

4.Social Security benefits

5.Worker's compensation

6.Public assistance List types

7.Other income Describe

8.Total monthly income (sum of items 1 through 7)

9.If your total monthly income is $0, explain your means of support




13.Basic communication

14.Necessary medical/dental

15.Necessary insurance

16.Transportation Number of vehicles

17.Child/dependent care

18.Required child/spousal support

19.Federal student loan payments

20.Private student loan payments

21.Other expenses Describe

22.Total monthly expenses (sum of items 10 through 21)

Page 1 of 5

Continue to Sections 3 and 4 on page 2.


Spouse's SSN

Borrower Name


Borrower SSN



Your family size includes you, your spouse, and your children (including unborn children who will be born before the end of the current calendar year), if the children will receive more than half of their support from you. Your family size includes other people only if they live with you now, receive more than half of their support from you now, and will continue to receive this support from you for the year for which you are certifying your family size. Support includes money, gifts, loans, housing, food, clothes, car, medical and dental care, and payment of college costs.

23.Family size

24.Are you requesting rehabilitation of a Direct Consolidation Loan or a Federal Consolidation Loan that was made jointly to you and your spouse?

Yes. Enter your spouse's name and SSN:

Spouse's Name

No. Continue to Section 4.


I understand that:

1.I have received this form because I requested the opportunity to rehabilitate my defaulted loans and objected to the reasonable and affordable monthly payment amount calculated using the 15% formula.

2.My loan holder will calculate an alternative reasonable and affordable monthly payment amount that will be based solely on the information I provide on this form and, if requested, supporting documentation.

3.If I do not accept either the 15% formula payment amount or the payment amount determined by my loan holder based on information from this form, the loan rehabilitation process will not proceed and I will be required to repay my defaulted loans in accordance with the terms of the loan and applicable law.

4.If I do not provide any supporting documentation requested by my loan holder by the deadline specified by my loan holder, my request for loan rehabilitation will not be considered.

5.If I want to rehabilitate a defaulted Direct Consolidation Loan or Federal Consolidation Loan that was made jointly to me and my spouse and am requesting an alternative payment amount, my spouse and I must each sign below.

6.If I rehabilitate a loan and default on the same loan again in the future, I may not rehabilitate that loan a second time.

7.I must notify my loan holder immediately if my address changes.

8.If my loan is rehabilitated, my loan will be sold or transferred to a new loan holder or loan servicer. After the sale or transfer, I will be asked to select a repayment plan. If I do not select a repayment plan, my loans will be placed on the standard repayment plan, which will likely require me to make a much higher monthly payment amount than the payment I made to rehabilitate my loan.

9.After my loan is rehabilitated, I may be eligible to repay my loans under an income-driven repayment plan that bases my payment on my income and family size. An income-driven repayment plan is the type of repayment plan most likely to have a monthly payment similar to the payment I made to rehabilitate my loans.

10.I can learn more about the eligibility requirements and application process for income-driven repayment plans by visiting StudentAid.gov/IDR or by asking my loan holder.

I certify that (1) the information that I have provided on this form is true and correct and (2) upon request, I will provide additional documentation to my loan holder to support the information I have provided in this form.

I authorize the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my request or my loans, including the repayment of my loans, at any number that I provide on this form or any future number that I provide for my cellular telephone or other wireless device using automated dialing equipment or artificial or prerecorded voice or text messages.

Borrower's Signature





Spouse's Signature

Your spouse must sign this form only if you entered your spouse's name and SSN in Section 3.

Page 2 of 5


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




Your loan holder may request supporting documentation for any income items.

Employment income documentation may include a pay stub or a letter from the employer stating the income paid to you by that employer.

Child support, Social Security benefits, worker’s compensation, or public assistance documentation may include copies of benefits checks or a benefits statement, a letter from a court, a governmental body, or the individual paying child support, specifying the amount of the benefit.

Public assistance: Identify the type of public assistance received (see definition of “public assistance” in Section 6).

Other income: Include any other income not covered in items 1-6 and identify the source of the income.

If you report that your Total Monthly Income is zero, explain your means of support in Item 9.


For each monthly expense, provide the amount you usually spend each month. Your loan holder may request supporting documentation for any of these items. Do not include a single expense in more than one category. If you have no expenses under a category, enter 0 for that category.

Food: Include the amount spent on food, even if purchased using the Supplemental Nutrition Assistance Program (SNAP) (food stamps).

Housing: Include the amount spent on housing and shelter, such as rent, required security deposits, mortgage payments (including principal, interest, taxes, and homeowner’s insurance), maintenance, and repairs.

Utilities: Include the amount spent on housing-related utility bills, such as gas, electric, fuel oil, water, sewer, trash, and recycling.

Insurance: Include the amount spent on insurance, such as necessary renter’s, auto, medical, dental, or life insurance. Include any amounts paid toward insurance premiums.

However, if the income amount you listed under Monthly Income already reflects deductions from your pay for insurance premiums, do not list the amount of these deductions as an Insurance expense. Include homeowner’s insurance under Item 11 (Housing).

Transportation: Include the amount spent on basic transportation expenses such as fuel, car payments, basic vehicle maintenance, public transportation, tolls, and parking. Also list the number of vehicles for which you are claiming related transportation expenses.

Child/dependent care: Include the amount spent on care for children or other dependents in the household and other work-related child/dependent care expenses.

Legally required child /spousal support: Include the amount spent on legally required child support and spousal support.

Federal student loan payments: Include the total monthly amount you pay on any federal student loans except for the defaulted loans you are trying to rehabilitate, unless you are subject to mandatory withholding such as wage garnishment or Treasury offset (e.g., your Social Security is being garnished). If you are subject to wage garnishment or Treasury offset include the amount that is collected from you each month.

Private student loan payments: Include the total monthly amount you pay on any private student loans. Include any type of payment, voluntary or otherwise.

Other expenses: Include the amount spent on any other necessary expenses not covered in items 10 - 20 and explain these expenses. These other expenses will be considered only if the Department of Education determines that they should be considered. If more space is needed to list other expenses, attach a separate piece of paper and include your name and Social Security Number at the top.

Page 3 of 5


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.




To rehabilitate your loan, you must accept either the monthly rehabilitation payment amount determined using the 15% formula, or the payment amount determined based on the monthly income, monthly expenses, and family size information that you provide on this form and on any requested supporting documentation.

Your loan holder will provide you with a written loan rehabilitation agreement confirming your monthly rehabilitation payment amount.

To accept the loan rehabilitation agreement, you must sign the agreement and return it to your loan holder.

During the loan rehabilitation period, the loan holder will limit contact with you on the loan being rehabilitated to collection activities that are required by law or regulation, and to communication that supports the rehabilitation.

If you do not accept either monthly payment amount, your rehabilitation request will not be considered any further.


Return the completed form and any documentation to: (If no address is shown, return to your loan holder.)

If you need help completing this form, call:

(If no telephone number is shown, call your loan holder.)

Page 4 of 5


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


(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


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.


Page 5 of 5

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Step 1: The initial step should be to hit the orange "Get Form Now" button.

Step 2: The document editing page is right now open. You can add text or manage present data.

These particular parts are contained in the PDF template you will be completing.

omb 1845 0120 fields to complete

You should fill in the MONTHLY INCOME, MONTHLY EXPENSES, Your employment income Spouses, List types Other income, Describe, Total monthly income sum of items, If your total monthly income is, Food Housing Utilities Basic, Number of vehicles Childdependent, Total monthly expenses sum of, Page of, and Continue to Sections and on page space with the appropriate data.

Filling out omb 1845 0120 part 2

You'll need to include specific data inside the space Borrower Name, Borrower SSN, SECTION FAMILY SIZE AND SPOUSE, Your family size includes you your, you and your spouse, Yes Enter your spouses name and SSN, Spouses Name No Continue to, Spouses SSN, SECTION UNDERSTANDINGS, I understand that, I have received this form because, My loan holder will calculate an, and solely on the information I.

Filling out omb 1845 0120 step 3

The I authorize the loan holder to, Borrowers Signature, Spouses Signature, Date, Date, Your spouse must sign this form, and Page of area is where each party can describe their rights and responsibilities.

Completing omb 1845 0120 step 4

Finalize by reading all of these sections and filling out the pertinent information: Return the completed form and any, If you need help completing this, and Page of.

omb 1845 0120 Return the completed form and any, If you need help completing this, and Page  of fields to fill out

Step 3: Select the Done button to save the form. At this point it is offered for transfer to your gadget.

Step 4: Make around several copies of the file to stay clear of any specific upcoming issues.

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