"Request Form for Reimbursement Due to Partial Discharge of a Federal Consolidation Loan (Loan Holder/Servicer)"

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REQUEST FOR REIMBURSEMENT DUE TO PARTIAL DISCHARGE
OF A FEDERAL CONSOLIDATION LOAN
(TO BE COMPLETED BY LOAN HOLDER/SERVICER)
Section I: DISCHARGE INFORMATION
1. Reason Type:
_____Closed School (CS)
_____Death (DE)
_____Disability (DI) _____False Certification (FC)
2. DCO: _____________________________________
Section II: BORROWER / CO-MAKER / DEPENDENT STUDENT INFORMATION
3. Borrower Name: _____________________________________________________________________ SSN:___________________________
4. Co-Maker Name: ____________________________________________________________________ SSN:___________________________
5. Dependent Student Name: _____________________________________________________________ SSN:___________________________
Section III: FEDERAL CONSOLIDATION LOAN INFORMATION
6. Loan ID
7. 1st Disb Date
8. Principal
9. Interest Rate/Type
_________________________
_________________________
$________________________
___________ / ____________
_________________________
_________________________
$________________________
___________ / ____________
_________________________
_________________________
$________________________
___________ / ____________
Total: $___________________
10. Proration Rate ______________________________%
Section IV: UNDERLYING INFORMATION
11. Loan Type
12. 1st Disb Date
11. Loan Type (cont)
12. 1st Disb Date (cont)
a. _______________________
a. _______________________
e. _______________________
e. _______________________
b. _______________________
b. _______________________
f. _______________________
f. _______________________
c. _______________________
c. _______________________
g. _______________________
g. _______________________
d. _______________________
d. _______________________
h. _______________________
h. _______________________
Section V: AMOUNT REQUESTED
13. Amount Requested: (Multiply total of #8 by #10)
$_________________________________
14. Int-Paid-Through Dt: ____________________________
15. Int Claimed as of: ___________________________
+ $_________________________________
16. Total Amount Requested:
= $_________________________________
17. Eligible Payments:
+ $_________________________________
18. Reimbursement Amount Requested:
$_________________________________
Section VI: LENDER INFORMATION
BY SUBMITTING THIS DOCUMENT TO THE GUARANTOR, THE LENDER/HOLDER CERTIFIES, TO THE BEST OF ITS
KNOWLEDGE, THE INFORMATION IN THIS DOCUMENT IS TRUE AND ACCURATE.
19. Lender ID: _______________________
20. Servicer ID: _______________________
21. Lender/Servicer Name/Address:__________________________________________________________________________________________
22. Prepared by:__________________________________ 23. Preparer’s # (______) _________________________________________________
Required Documentation:
Closed School (CS) = School Closure Loan Discharge Application
Death (DE) = Original or Certified Copy of Death Certificate
Disability (DI) = Copy of the Department of Education’s official notification that the disability
discharge application has been approved
False Certification (FC) = False Certification Loan Discharge Application
1403-59134
04/14
REQUEST FOR REIMBURSEMENT DUE TO PARTIAL DISCHARGE
OF A FEDERAL CONSOLIDATION LOAN
(TO BE COMPLETED BY LOAN HOLDER/SERVICER)
Section I: DISCHARGE INFORMATION
1. Reason Type:
_____Closed School (CS)
_____Death (DE)
_____Disability (DI) _____False Certification (FC)
2. DCO: _____________________________________
Section II: BORROWER / CO-MAKER / DEPENDENT STUDENT INFORMATION
3. Borrower Name: _____________________________________________________________________ SSN:___________________________
4. Co-Maker Name: ____________________________________________________________________ SSN:___________________________
5. Dependent Student Name: _____________________________________________________________ SSN:___________________________
Section III: FEDERAL CONSOLIDATION LOAN INFORMATION
6. Loan ID
7. 1st Disb Date
8. Principal
9. Interest Rate/Type
_________________________
_________________________
$________________________
___________ / ____________
_________________________
_________________________
$________________________
___________ / ____________
_________________________
_________________________
$________________________
___________ / ____________
Total: $___________________
10. Proration Rate ______________________________%
Section IV: UNDERLYING INFORMATION
11. Loan Type
12. 1st Disb Date
11. Loan Type (cont)
12. 1st Disb Date (cont)
a. _______________________
a. _______________________
e. _______________________
e. _______________________
b. _______________________
b. _______________________
f. _______________________
f. _______________________
c. _______________________
c. _______________________
g. _______________________
g. _______________________
d. _______________________
d. _______________________
h. _______________________
h. _______________________
Section V: AMOUNT REQUESTED
13. Amount Requested: (Multiply total of #8 by #10)
$_________________________________
14. Int-Paid-Through Dt: ____________________________
15. Int Claimed as of: ___________________________
+ $_________________________________
16. Total Amount Requested:
= $_________________________________
17. Eligible Payments:
+ $_________________________________
18. Reimbursement Amount Requested:
$_________________________________
Section VI: LENDER INFORMATION
BY SUBMITTING THIS DOCUMENT TO THE GUARANTOR, THE LENDER/HOLDER CERTIFIES, TO THE BEST OF ITS
KNOWLEDGE, THE INFORMATION IN THIS DOCUMENT IS TRUE AND ACCURATE.
19. Lender ID: _______________________
20. Servicer ID: _______________________
21. Lender/Servicer Name/Address:__________________________________________________________________________________________
22. Prepared by:__________________________________ 23. Preparer’s # (______) _________________________________________________
Required Documentation:
Closed School (CS) = School Closure Loan Discharge Application
Death (DE) = Original or Certified Copy of Death Certificate
Disability (DI) = Copy of the Department of Education’s official notification that the disability
discharge application has been approved
False Certification (FC) = False Certification Loan Discharge Application
1403-59134
04/14
Instructions for Reimbursement Due to Partial Discharge of a Federal Consolidation Loan
Use this form only if you are requesting reimbursement for the partial discharge of a Federal Consolidation loan due to the death of a dependent student for whom a
PLUS loan was received and later consolidated, the death or total and permanent disability of one of two borrowers on a spousal Federal Consolidation loan, or the
discharge of an underlying loan(s) due to a closed school or false certification situation. All date fields must be completed with numerics in MM/DD/CCYY format. If
all the loans consolidated are eligible for discharge, you must file a request for discharge with the guarantor using the Claim Form.
I.
DISCHARGE INFORMATION
1. Reason Type: Select the appropriate reason for partial discharge: Closed School (CS) / Death (DE) / Disability (DI) / False Certification (FC).
2. DCO: Date Condition Occurred is defined by the Reason Type indicated in Field 1. Provide the corresponding month, day, and year as follows:
- If Reason Type is “CS” (Closed School), provide the date you received the statement from the borrower certifying eligibility for a Closed School discharge or
the date the guarantor advised you to file a claim.
- If Reason Type is “DE” (Death), provide the date you received official notification of the death of the borrower or, if applicable, the student.
- If Reason Type is “DI” (Disability – total and permanent), provide the date you received a completed loan discharge application or, for DI claims based on the
Department of Education’s determination of discharge eligibility, the date you received official notification that the borrower’s disability discharge application
has been approved.
- If Reason Type is “FC” (False Certification), provide the date you received the statement from the borrower certifying eligibility for a False Certification dis-
charge or the date the guarantor advised you to file a claim.
II. BORROWER/CO-MAKER/DEPENDENT STUDENT INFORMATION
3. Borrower Name/SSN: Provide the last name, first name, middle initial and Social Security Number of the borrower identified on your system to which the
Federal Consolidation loan was made.
4. Co-Maker Name/SSN: Provide the last name, first name, middle initial and Social Security Number of the co-maker to whom the Federal Consolidation loan
was made, if applicable.
5. Dependent Student Name/SSN: Provide the last name, first name, middle initial and Social Security Number of the dependent student on the underlying PLUS
loan(s), if applicable.
III. FEDERAL CONSOLIDATION LOAN INFORMATION
6. Loan ID: Provide the loan identifier code, file number, guarantee date, or guarantee amount, as required by the guarantor of the loan.
7. 1st Disb Date: Provide the date of the first disbursement.
8. Principal: If the date of death or disability is on or after the date of consolidation, enter the total amount of principal outstanding on the Federal Consolidation
loan as of the date the borrower or student died or the date the borrower became disabled. If the date of disability is prior to the date of consolidation, or the re-
quest Reason Type is CS or FC, enter the total amount paid by the consolidation lender to the prior holder(s) for all underlying loans. Total the principal amounts.
9. Interest Rate/Type: Provide the current interest rate and indicate the type of interest rate by entering the appropriate code: F = fixed rate; V = variable rate.
10. Proration Rate: Enter the result of dividing the total amount paid at consolidation on the underlying loan(s) eligible for discharge by the total amount of all
loans consolidated, calculated to the 4th decimal place.
IV. UNDERLYING LOAN INFORMATION
Provide the Loan Type and 1st Disbursement Date for each underlying loan that is requested for discharge. If the number of loans exceeds the space provided, attach a
separate Request for Reimbursement Due to Partial Discharge of a Federal Consolidation Loan form with Section II (borrower/dependent student information) and
Section IV (underlying loan information) completed.
11. Loan Type: For each loan listed, provide the loan type using one of the following codes:
SS
Subsidized Federal Stafford Loans
HEAL
Health Education Assistance Loans
DSS
Direct Subsidized Stafford Loans
FISL
Federal Insured Student Loans
US
PLUS
Unsubsidized and Nonsubsidized Federal Stafford Loans
Federal PLUS (parent) Loans
DPLUS Direct PLUS Loans
DUS
SCON
Direct Unsubsidized Stafford Loans
Subsidized Federal Consolidation Loans
SLS
Federal Supplemental Loans for Students (formerly Auxiliary
DSCON Direct Subsidized Consolidation Loans
GB
Loans to Assist Student (ALAS) and Student PLUS Loans)
Federal PLUS Loans (for graduate/professional students)
UCON Unsubsidized Federal Consolidation Loans
PERK Federal Perkins Loans formerly National Defense/National
DUCON Direct Unsubsidized Consolidation Loan
Direct Student Loans (NDSL)
D3
Direct PLUS Loans (for graduate/professional students)
HPSL
NSL
Health Professions Student Loans, including Loans for
Federal Nursing Loans
Disadvantaged Students
12. 1st Disb Date: Provide the date of the first disbursement for each underlying loan listed in this Section.
V. AMOUNT REQUESTED
13. Amount Requested: Provide the principal amount requested for reimbursement by multiplying the total amount in field 8, Principal, by field 10, Proration Rate.
14. Int-Paid-Through Dt: If the date of death or disability is on or after consolidation, provide the date through which interest was last paid on the amount of the
applicable underlying loan(s) as of the date of death or disability. If the date of disability is prior to consolidation, or if the request Reason Type is CS or FC,
provide the date of the consolidation. Note: If a subsidized deferment has been applied to the Federal Consolidation loan, the Interest Paid Through Date may
need to be adjusted.
15. Int Claimed as Of: Provide the date through which interest requested was accrued and the amount of interest accrued as follows:
For a date of death or disability on or after consolidation, calculate from the Int-Paid-Through Dt in field 14 through the date interest was requested on the
amount of the applicable underlying loan(s). For a date of disability prior to consolidation or for a request Reason Type of CS or FC, calculate from the date of
consolidation through the date interest was requested on the amount of the applicable underlying loan(s). Note: If a subsidized deferment has been applied to the
Federal Consolidation loan, adjust the interest claimed as of amount to exclude this interest.
16. Total Amount Requested: Provide the total amount requested for reimbursement; calculated by adding the amounts in fields 13 and 15.
17. Eligible Payments: For request Reason Types CS and FC, provide the total amount of all payments made by or on behalf of the borrower that were applied to
the eligible underlying loan(s), prior to consolidation, if known. For request Reason Type DI, provide the total amount of all payments made by or on behalf
of the borrower and received by the lender after (on or after, for determinations based on VA documentation) the date of disability, but prior to the date of the
Federal Consolidation loan, which were applied to the underlying loan(s) eligible for discharge, if known.
18. Reimbursement Amount Requested: Enter total reimbursement amount requested; calculated by adding amounts in fields 16 and 17.
VI. LENDER INFORMATION
19. Lender ID: Provide the six-digit Department of Education lender code and, as applicable, the four-digit non-Department of Education suffix of the lender or
the current holder.
20. Servicer ID: If the account is being serviced, provide the six-digit Department of Education servicer code.
21. Lender/Servicer Name/Address: If the account is being serviced, provide the servicer’s name and address. If there is no servicer, provide the lender’s name
and address.
22. Prepared By: Provide the name of the person or unit responsible for answering questions about information provided on this form.
23. Preparer’s #: Provide the phone number (including area code) where the preparer may be reached.
1403-59134
04/14
Reimbursement Request Form Request Form

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