"Income-Based Repayment Plan Alternative Documentation of Income"

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Income-Based Repayment Plan
OMB No. 1845-0102
Alternative Documentation of Income
Form Approved
Exp. Date 04/30/2013
Federal Family Education Loan Program
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 fines, 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 filed federal income tax return, does not reasonably reflect your current income (and/or
your spouse’s current income, if you are married and file 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 filed federal income tax return, does not reasonably reflect your current income (and/or your spouse’s current income, if you are married and file a joint
federal income tax return);
(3) You have been notified 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 notified your loan holder that you are not required to file 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 file 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 file 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 file 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.
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 file a joint federal income tax return and your spouse does not have any income or receives only untaxed income such as Supplemental
r
Security Income, child support, or federal or state public assistance.
Complete the items below by entering your annual taxable income (as defined above).
Your annual taxable income: $_____________________ (as supported by the documentation you provide)
Your spouse’s annual taxable income, if you are married and file 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)
I 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
n
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
artificial or prerecorded voice or text messages.
n I 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 file
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.
n I 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)
Page 1 of 2
Income-Based Repayment Plan
OMB No. 1845-0102
Alternative Documentation of Income
Form Approved
Exp. Date 04/30/2013
Federal Family Education Loan Program
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 fines, 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 filed federal income tax return, does not reasonably reflect your current income (and/or
your spouse’s current income, if you are married and file 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 filed federal income tax return, does not reasonably reflect your current income (and/or your spouse’s current income, if you are married and file a joint
federal income tax return);
(3) You have been notified 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 notified your loan holder that you are not required to file 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 file 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 file 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 file 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.
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 file a joint federal income tax return and your spouse does not have any income or receives only untaxed income such as Supplemental
r
Security Income, child support, or federal or state public assistance.
Complete the items below by entering your annual taxable income (as defined above).
Your annual taxable income: $_____________________ (as supported by the documentation you provide)
Your spouse’s annual taxable income, if you are married and file 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)
I 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
n
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
artificial or prerecorded voice or text messages.
n I 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 file
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.
n I 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)
Page 1 of 2
SECTION 6: WHERE TO SEND THE COMPLETED IBR PLAN ALTERNATIVE DOCUMENTATION OF INCOME FORM
Return the completed IBR Plan Alternative Documentation of Income form
If you need help completing this form, call:
and any required documentation to: (If no address is shown, return to your
(If no telephone number is shown, call your loan holder.)
loan holder.)
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 benefit 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 identifier and to permit you to access your account information
electronically. The information in your file 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 financial and educational institutions, and to guaranty agencies
in order to verify your identity, to determine your eligibility to receive a loan or a benefit 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 financial 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 financial and educational institutions, or to state agencies. To provide financial
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 financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions efficiently to submit student
enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty
agencies, to financial 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 qualified 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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