Income Based Repayment Plan Form – Fill Out and Use This PDF

IBR ALT DOC

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents is subject to

penalties that may include ines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: BORROWER IDENTIFICATION

Please enter or correct the following information.

SSN

Name _____________________________________________________________

Address ____________________________________________________________

City, State, Zip Code

__________________________________________________

Telephone - Home (

) _____________________________________________

Telephone - Other (

) _____________________________________________

E-mail Address (Optional) ______________________________________________

SECTION 2: INSTRUCTIONS AND INFORMATION

Type or print using dark ink. If you need help completing this form, contact your loan holder. Return the completed form and any required documentation to the address shown in Section 6.

Complete this form if you want to repay or continue to repay your eligible Federal Family Education Loan Program (FFELP) loan(s) under the Income-Based Repayment (IBR) plan and:

(1)You believe that your adjusted gross income (AGI), as reported on your most recently iled federal income tax return, does not reasonably relect your current income (and/or your spouse’s current income, if you are married and ile a joint federal income tax return); your loan holder will make this determination based on the information you provide with this form;

(2)Your loan holder has requested that you provide alternative documentation of income because your loan holder believes that your adjusted gross income (AGI), as reported on your most recently iled federal income tax return, does not reasonably relect your current income (and/or your spouse’s current income, if you are married and ile a joint federal income tax return);

(3)You have been notiied by your loan holder that the Internal Revenue Service (IRS) is unable to provide your loan holder with documentation of your AGI; or

(4)You have notiied your loan holder that you are not required to ile a federal income tax return for the most recently ended tax year.

The amount of your monthly payment under the IBR plan is based on your current income (and your spouse’s current income, if you are married and ile a joint federal income tax return) and is reevaluated annually. To submit alternative documentation of your income, you must attach documentation of that income as described in Section 4, complete this form, including your signature in Section 5, and return it to the address shown in Section 6. If you are married and ile a joint federal income tax return, your spouse must also sign in Section 5.

SECTION 3: SPOUSE INFORMATION (IF YOU ARE MARRIED AND FILE A JOINT FEDERAL INCOME TAX RETURN)

Name

	Last	First		Middle Initial
Address
	Number and Street	City	State	Zip Code

SECTION 4: INCOME INFORMATION (MUST BE COMPLETED BY THE BORROWER AND SPOUSE, IF MARRIED AND FILE A JOINT FEDERAL INCOME TAX RETURN)

You must provide your total annual taxable income from all sources that you currently receive (for example, income from employment, unemployment income, dividend income, interest income, tips, alimony). If you are married and ile a joint federal income tax return, you must also provide your spouse’s annual taxable income. Do not report untaxed income such as Supplemental Security Income, child support, or federal or state public assistance.

You must provide supporting documentation for all income (yours and your spouse’s) reported in this section (for example, pay stubs, letters from your employers listing income, interest or bank statements, dividend statements), or, if these forms of documentation are unavailable, a signed statement explaining the income source(s) and giving the name and the address of the source(s). The date on any supporting documentation you provide must be no older than 90 days from the date you sign this form.

Your eligibility for the IBR plan and your payment amount will be determined based on your annual income as supported by the documentation you provide.

r Check this box if you do not have any income or receive only untaxed income such as Supplemental Security Income, child support, or federal or state public assistance.

r Check this box if you are married and ile a joint federal income tax return and your spouse does not have any income or receives only untaxed income such as Supplemental Security Income, child support, or federal or state public assistance.

Complete the items below by entering your annual taxable income (as deined above).

Your annual taxable income: $_____________________ (as supported by the documentation you provide)

Your spouse’s annual taxable income, if you are married and ile a joint federal income tax return: $_____________________ (as supported by the documentation you provide)

SECTION 5: AUTHORIZATION, UNDERSTANDINGS, CERTIFICATION AND SIGNATURE

(MUST BE COMPLETED BY THE BORROWER AND SPOUSE, IF MARRIED AND FILE A JOINT FEDERAL INCOME TAX RETURN)

nI authorize the school, the lender, the guarantor, the U.S. Department of Education, and their respective agents and contractors to contact me regarding my loan(s), including repayment of my loan(s), at the current or any future number that I provide for my cellular telephone or other wireless device using automated telephone dialing equipment or artiicial or prerecorded voice or text messages.

nI understand that my income information may be requested from the IRS even if alternative documentation of my income is accepted. I understand that if I am married and ile a joint federal income tax return with my spouse, my spouse’s income information, documentation, and signature are required. I understand I must agree to provide to the loan holder on an annual basis documentation of my income for the purpose of determining my monthly payment amount under the IBR plan.

nI certify that all of the information I have provided on this form and in any accompanying documentation is true, complete, and correct to the best of my knowledge and belief.

Borrower Signature			Date (mm-dd-yyyy)
Spouse Signature (if required)			Date (mm-dd-yyyy)

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SECTION 6: WHERE TO SEND THE COMPLETED IBR PLAN ALTERNATIVE DOCUMENTATION OF INCOME FORM

SECTION 7: IMPORTANT NOTICES

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you:

The authority for collecting the requested information from and about you is §428(b)(2)(A) et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1078(b)(2)(A) et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Education Loan (FFEL) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate.

The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a beneit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the FFEL Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. We also use your SSN as an account identiier and to permit you to access your account information electronically. The information in your ile may be disclosed, on a case-by-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to inancial and educational institutions, and to guaranty agencies

in order to verify your identity, to determine your eligibility to receive a loan or a beneit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student inancial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to inancial and educational institutions, or to state agencies. To provide inancial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to inancial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions eficiently to submit student enrollment status, disclosures may be made to guaranty agencies or to inancial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to inancial and educational institutions, or to federal, state, or local agencies.

In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualiied researchers under Privacy

Act safeguards.

Paperwork Reduction Notice

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0102. The time required to complete this information collection is estimated to average one hour (60 minutes) per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the information collection. If you

have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:

U.S. Department of Education, Washington, DC 20202-4651

If you have any comments or concerns regarding the status of your individual submission of this form, write directly to the address shown in Section 6.

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