How Do I Apply for a Total and Permanent Disability Discharge of My FEDERAL* Student Loans?

Transcription

1 Hw D I Apply fr a Ttal and Permanent Disability Discharge f My FEDERAL* Student Lans?

2 Ttal and Permanent Disability Discharge fr Federal Student Lans

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9 SAMPLE DISCHARGE APPLICATION

10 SAMPLE DISCHARGE APPLICATION OMB N Frm Apprved Exp. Date 6/30/2016 TPD-APP DISCHARGE APPLICATION: TOTAL AND PERMANENT DISABILITY IMPORTANT INFORMATION William D. Frd Federal Direct Lan Prgram Federal Family Educatin Lan Prgram Federal Perkins Lan Prgram TEACH Grant Prgram READ THIS FIRST This is an applicatin fr a ttal and permanent disability discharge f yur William D. Frd Federal Direct Lan (Direct Lan) Prgram, Federal Family Educatin Lan (FFEL) Prgram, and/r Federal Perkins Lan (Perkins Lan) Prgram lan(s), and/r yur Teacher Educatin Assistance fr Cllege and Higher Educatin (TEACH) Grant Prgram service bligatin. Yu nly need t submit a single applicatin t the U.S. Department f Educatin t apply fr discharge f all f yur Direct Lan, FFEL, and/r Perkins Lan prgram lans and yur TEACH Grant service bligatins. Thrughut this applicatin, the wrds we, us, and ur refer t the U.S. Department f Educatin. T qualify fr this discharge, yu must meet ne f the fllwing requirements: 1. Yu are a veteran wh has been determined by the U.S. Department f Veterans Affairs (VA) t be unemplyable due t a servicecnnected disability, and yu prvide dcumentatin frm the VA f that determinatin; OR 2. Yu have received a Scial Security Administratin (SSA) ntice f award fr Scial Security Disability Insurance (SSDI) r Supplemental Security Incme (SSI) stating that yur next scheduled disability review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin, and yu prvide a cpy f that SSA ntice f award. OR 3. Yu prvide a certificatin frm a physician in Sectin 4 f this Discharge Applicatin that yu are unable t engage in any substantial gainful activity (see definitin in Sectin 5) by reasn f a medically determinable physical r mental impairment that: Can be expected t result in death; Has lasted fr a cntinuus perid f nt less than 60 mnths; r Can be expected t last fr a cntinuus perid f nt less than 60 mnths. If yu d nt meet requirement #1 r requirement #2, yu may qualify fr discharge by btaining a certificatin frm a physician in Sectin 4 f this applicatin, as described abve fr requirement #3. If yu can prvide the dcumentatin t shw that yu meet requirement #1 r #2 abve, yu are nt required t have a physician cmplete Sectin 4. If yu are a veteran applying fr discharge under requirement #1, yu must prvide dcumentatin frm the VA shwing that the VA has determined that yu are unemplyable due t a service-cnnected disability. Yu d nt meet this requirement if yur disability is nt servicecnnected. The fllwing tw types f VA determinatins meet this requirement: (1) a determinatin that yu have a service-cnnected disability (r disabilities) that is 100% disabling; r (2) a determinatin that yu are ttally disabled based n an individual unemplyability determinatin. If yu are applying fr discharge under requirement #2, the SSA ntice f award that yu prvide must shw that yur next scheduled disability review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin. Yu d nt meet this requirement if the ntice f award states that yur next scheduled disability review will be within less than 5 years. If the ntice f award des nt clearly state the date f yur next scheduled review, cntact the SSA ffice that issued the award and request a Benefits Planning Query (BPQY). The BPQY prvides a summary f yur SSA disability benefits, including the scheduled date fr yur next disability review. If yur BPQY shws that yur next scheduled review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin, yu may submit a cpy f yur BPQY t shw that yu meet requirement #2. If yu are granted a discharge based n requirement #2 r requirement #3, we will mnitr yur status during a 3-year pst-discharge mnitring perid. Yur discharged lans r TEACH Grant service bligatin may be reinstated if yu d nt meet certain requirements during this perid, as explained in Sectin 6 f this frm. Except fr VA r SSA determinatins as described abve (requirements #1 and #2), a disability determinatin by anther federal r state agency des nt qualify yu fr this discharge. Lan amunts discharged due t ttal and permanent disability may be cnsidered taxable incme by the Internal Revenue Service (IRS). Cntact the IRS fr mre infrmatin. If yu wish t designate an individual r rganizatin t represent yu in matters related t yur ttal and permanent disability discharge request, yu must cmplete the Ttal and Permanent Disability: Applicant Representative Designatin frm. Yu may btain this frm frm ur Ttal and Permanent Disability Discharge Servicer (see belw fr cntact infrmatin). Befre submitting yur applicatin, make sure that Sectin 3 and (if required) Sectin 4 include all requested infrmatin. Incmplete r inaccurate infrmatin may cause yur applicatin t be delayed r rejected. WHERE TO SEND YOUR COMPLETED DISCHARGE APPLICATION Send yur cmpleted applicatin with any required dcumentatin (see the instructins in Sectin 2 n page 2) t the fllwing address: U.S. Department f Educatin TPD Servicing PO Bx Lincln, NE If yu need help cmpleting this frm, cntact ur Ttal and Permanent Disability Discharge Servicer: Phne: disabilityinfrmatin@nelnet.net Web site: Page 1 f 7

11 OMB N Frm Apprved Exp. Date 6/30/2016 DISCHARGE APPLICATION: TOTAL AND PERMANENT DISABILITY William D. Frd Federal Direct Lan, Federal Family Educatin Lan, Federal Perkins Lan, and TEACH Grant Prgrams WARNING: Any persn wh knwingly makes a false statement r misrepresentatin n this frm r n any accmpanying dcuments will be subject t penalties that may include fines, imprisnment, r bth, under the U.S. Criminal Cde and 20 U.S.C SECTION 1: APPLICANT IDENTIFICATION SECTION 2: INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION All applicants must cmplete this sectin. Please enter r crrect the fllwing infrmatin. Check this bx if any f yur infrmatin has changed. SSN DOB Name Address Albert Einstein 112 Mercer St. City, State, Zip Cde Princetn, NJ Telephne ( 609 ) Address (Optinal) albert@einstein.cm Carefully read the entire applicatin, including page 1, the instructins in this sectin, and the additinal infrmatin n the fllwing pages. Type r print in dark ink. Sign and date the applicatin in Sectin 3. If yu are required t have a physician cmplete Sectin 4, enter yur name and Scial Security Number at the tp f page 2 (if nt preprinted). Send the cmpleted applicatin with any required dcumentatin t: U.S. Department f Educatin, TPD Servicing, PO Bx 87130, Lincln, NE Are yu a veteran wh has received a determinatin frm the U.S. Department f Veterans Affairs (VA) that yu are unemplyable due t a servicecnnected disability? Yes Attach dcumentatin f the VA determinatin and cmplete Sectin 3. Yu are nt required t have a physician cmplete Sectin 4. N Cntinue t Item Have yu received an SSA ntice f award fr SSDI r SSI benefits r an SSA Benefits Planning Query (BPQY) stating that yur next scheduled disability review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin? Yes Attach a cpy f the SSI SSA ntice r f award SSDI r BPQY and benefits. cmplete Sectin 3. Yu Otherwise, are nt required t have check a physician cmplete "NO". Sectin 4. N Cmplete Sectin 3 and have a physician wh is a dctr f medicine r stepathy cmplete and sign Sectin 4. Yu must submit this applicatin t us within 90 days f the date f yur physician s signature in Sectin 4. SECTION 3: APPLICANT S DISCHARGE REQUEST, AUTHORIZATION, UNDERSTANDINGS, AND CERTIFICATIONS I request that the U.S. Department f Educatin discharge my Direct Lan, FFEL, and/r Perkins Lan, prgram lan(s), and/r my TEACH Grant service bligatin. I authrize any physician, hspital, r ther institutin having recrds abut the disability that is the basis fr my request fr a discharge t make infrmatin frm thse recrds available t the U.S. Department f Educatin. I understand that: Check "YES" if yu are applying as a veteran with VA certificatin. Otherwise, check "NO". Check "YES" if yu are applying because yu receive (1) If I am applying fr discharge based n a physician s certificatin in Sectin 4, I must submit this applicatin t the U.S. Department f Educatin within 90 days f the date f my physician s signature in Sectin 4. (2) Unless I am a veteran wh prvides the dcumentatin described abve in Sectin 2, Item 1, I may be required t repay a discharged lan r satisfy a discharged TEACH Grant service bligatin if I fail t meet certain requirements during a pst-discharge mnitring perid, as explained in Sectin 6. (3) If I am a veteran wh des nt meet the requirement described abve in Sectin 2, Item 1, and I have btained a certificatin frm a physician in Sectin 4, the certificatin by the physician n this frm is nly fr the purpses f establishing my eligibility t receive a discharge f a Direct Lan Prgram lan, a FFEL Prgram Lan, a Perkins Lan Prgram lan, and/r a TEACH Grant service bligatin, and is nt fr purpses f determining my eligibility fr, r the extent f my eligibility fr, VA benefits. All applicants must sign and date here. (4) If I wish t designate an individual r rganizatin t represent me in matters related t my ttal and permanent disability discharge request, I must cmplete and submit the Ttal and Permanent Disability Discharge: Applicant Representative Designatin frm. I certify that: (1) I have a ttal and permanent disability, as defined in Sectin 5; and (2) I have read and understand the infrmatin n the discharge prcess, the terms and cnditins fr discharge, and the eligibility requirements t receive future lans r TEACH Grants as explained in Sectins 6 and 7. Signature f Applicant r Applicant s Representative (see NOTE belw) Date Printed Name f Representative (if applicable) NOTE: Yu may designate an individual r rganizatin t represent yu in matters related t yur ttal and permanent disability discharge request. If yu wish t designate a representative, yu must cmplete the Ttal and Permanent Disability: Applicant Representative Designatin frm. Yu may btain this frm frm ur Ttal and Permanent Disability Discharge Servicer. See the Read This First sectin f this frm fr cntact infrmatin. Page 2 f 7

12 Applicant Name: Albert Einstein Applicant SSN: SECTION 4: PHYSICIAN S CERTIFICATION Infrmatin and Instructins fr Physician: The applicant identified abve is applying fr a discharge f a federal student lan and/r a teaching service bligatin fr a federal grant n the basis that he r she has a ttal and permanent disability, as defined in Sectin 5 f this frm. T qualify fr a discharge, the applicant must be unable t engage in any substantial gainful activity (as defined belw and in Sectin 5) by reasn f a medically determinable physical r mental impairment that (1) can be expected t result in death; r (2) has lasted fr a cntinuus perid f nt less than 60 mnths; r (3) can be expected t last fr a cntinuus perid f nt less than 60 mnths. This disability standard may be different frm All standards applicants used under ther prgrams must in cnnectin with ccupatinal disability, r eligibility fr scial service r veterans benefits. A determinatin that the applicant is disabled by anther federal agency (fr example, the Scial Security Administratin) r a state agency des nt autmatically establish the cmplete applicant s eligibility this fr lan sectin discharge. Cmplete this frm nly if yu are a dctr f medicine r stepathy legally authrized t practice in a state, as defined in Sectin 5, and nly if the applicant s cnditin meets the definitin f ttal at and permanent the tp disability f in Sectin this 5. page. Print legibly in dark ink r type. All fields must be cmpleted. If a field is nt applicable, enter N/A. Yur signature date must include mnth, day, and year (mm-dd-yyyy). Prvide all requested infrmatin fr Items 1, 2, and 3 belw, and attach additinal pages if necessary. Cmplete the physician s certificatin at the bttm f this page. The applicant s lan discharge applicatin cannt be prcessed if the infrmatin requested in this sectin is missing r if yur signature is missing. If yu make any changes t the infrmatin yu prvide in this sectin, yu must initial each change. Please return the cmpleted frm t the applicant r the applicant s representative. The U.S. Department f Educatin may cntact yu fr additinal infrmatin r dcumentatin. 1. Medically Determinable Physical r Mental Impairment. Des the applicant have a medically determinable physical r mental impairment that (a) prevents the applicant frm engaging in any substantial gainful activity, in any field f wrk, and (b) can be expected t result in death, r has lasted fr a cntinuus perid f nt less than 60 mnths, r can be expected t last fr a cntinuus perid f nt less than 60 mnths? Yes N Substantial gainful activity means a level f wrk perfrmed fr pay r prfit that invlves ding significant physical r mental activities, r a cmbinatin f bth. If the applicant is able t engage in any substantial gainful activity, in any field f wrk, yu must answer N. The determinatin f whether r nt the applicant can perfrm substantial gainful activity is nt based n whether the applicant can perfrm his r her current r past jb r prfessin. IF THE ANSWER TO QUESTION 1 IS NO, DO NOT COMPLETE THIS APPLICATION. 2. Disabling Cnditin. Cmplete Items (a) and (b) regarding the applicant s disabling impairment. D nt use abbreviatins r insurance cdes. (a) Prvide yur diagnsis f the applicant s impairment: (b) Describe the severity f the disabling physical r mental impairment, including, if applicable, the phase f the disabling cnditin: 3. Limitatins. Explain hw the disabling cnditin prevents the applicant frm engaging in substantial gainful activity in any field f wrk by respnding t Items (a) thrugh (e) belw, as relevant t the applicant s cnditin. Attach additinal pages if mre space is needed. In additin t what is required belw, yu may include any additinal infrmatin that yu believe wuld be helpful in understanding the applicant s cnditin, such as medicatins used t treat the cnditin, surgical and nn-surgical treatments fr the cnditin, etc. (a) Limitatins n sitting, standing, walking, r lifting: (b) Limitatins n activities f daily living: (c) Residual functinality: (d) Scial/behaviral limitatins, if any: If yu are applying with a physician's certificatin f yur disability, have the physician cmplete the rest f this page. Otherwise, leave the rest f this page blank. (e) Current Glbal Assessment Functin Scre (fr psychiatric cnditins): Physician s Certificatin I certify that, in my best prfessinal judgment, the applicant identified abve is unable t engage in any substantial gainful activity in any field f wrk by reasn f a medically determinable physical r mental impairment that (1) can be expected t result in death; r (2) has lasted fr a cntinuus perid f nt less than 60 mnths; r (3) can be expected t last fr a cntinuus perid f nt less than 60 mnths. I understand that an applicant wh is currently able t engage in any substantial gainful activity in any field f wrk des nt have a ttal and permanent disability as defined n this frm. I am a dctr f (check ne) medicine stepathy/stepathic medicine. I am legally authrized t practice in the state identified belw and I have prvided my prfessinal license number belw. State Where Legally Authrized t Practice Prfessinal License Number(stamp is acceptable; subject t verificatin thrugh state recrds) Physician s Signature (a signature stamp is nt acceptable) Date (mm-dd-yyyy) Printed Name f Physician (first name, middle initial, last name) Address (stamp is acceptable) City, State, Zip Cde ( ) ( ) Telephne Fax Address (Optinal) Page 3 f 7

13 SECTION 5: DEFINITIONS If yu have a ttal and permanent disability, this means that: (1) Yu are unable t engage in any substantial gainful activity by reasn f a medically determinable physical r mental impairment that can be expected t result in death, r that has lasted fr a cntinuus perid f nt less than 60 mnths, r that can be expected t last fr a cntinuus perid f nt less than 60 mnths; OR (2) Yu are a veteran wh has been determined by the VA t be unemplyable due t a service-cnnected disability. IMPORTANT INFORMATION ABOUT THE DEFINITION OF TOTAL AND PERMANENT DISABILITY : T demnstrate that yu have a ttal and permanent disability in accrdance with paragraph (1) f this definitin, yu must either (a) prvide a cpy f an SSA ntice f award fr SSDI r SSI benefits r an SSA Benefits Planning Query (BPQY) stating that yur next scheduled disability review will be 5 t 7 years frm the date f yur last SSA disability determinatin, r (b) have a physician wh is a dctr f medicine r stepathy cmplete Sectin 4 f this applicatin. T demnstrate that yu have a ttal and permanent disability in accrdance with paragraph (2) f this definitin, yu must prvide dcumentatin f a determinatin frm the VA that yu are unemplyable due t a service-cnnected disability See page 1 f this frm fr mre infrmatin n acceptable dcumentatin. The abve definitin f ttal and permanent disability may differ frm disability standards used by ther federal agencies Except fr certain individuals wh have received SSA ntices f award fr SSDI r SSI benefits, as explained abve, r fr certain veterans, a disability determinatin by anther federal r state agency des nt establish yur eligibility fr a discharge f yur lan(s) and/r TEACH Grant service bligatin due t a ttal and permanent disability. Substantial gainful activity means a level f wrk perfrmed fr pay r prfit that invlves ding significant physical r mental activities, r a cmbinatin f bth. A discharge f a lan due t a ttal and permanent disability cancels yur bligatin (and, if applicable, an endrser s bligatin) t repay the remaining balance n yur Direct Lan, FFEL, and/r Perkins Lan prgram lans. A discharge f a TEACH Grant service bligatin cancels yur bligatin t cmplete the teaching service that yu agreed t perfrm as a cnditin fr receiving a TEACH Grant. The pst-discharge mnitring perid begins n the date we grant a discharge f yur lan(s) r TEACH Grant service bligatin and lasts fr three years. If yu fail t meet certain cnditins at any time during r at the end f the pst-discharge mnitring perid, we will reinstate yur bligatin t repay yur lan(s) r cmplete yur TEACH Grant service. See Sectin 6 fr mre infrmatin. Nte t Veterans: The pst-discharge mnitring perid des nt apply if yu are a veteran wh receives a discharge based n a determinatin frm the VA that yu are unemplyable due t a service-cnnected disability. The William D. Frd Federal Direct Lan (Direct Lan) Prgram includes Federal Direct Staffrd/Frd Lans (Direct Subsidized Lans), Federal Direct Unsubsidized Staffrd/Frd Lans (Direct Unsubsidized Lans), Federal Direct PLUS Lans (Direct PLUS Lans), and Federal Direct Cnslidatin Lans (Direct Cnslidatin Lans). The Federal Family Educatin Lan (FFEL) Prgram includes Federal Staffrd Lans (bth subsidized and unsubsidized), Federal Supplemental Lans fr Students (SLS), Federal PLUS Lans, and Federal Cnslidatin Lans. The Federal Perkins Lan (Perkins Lan) Prgram includes Federal Perkins Lans, Natinal Direct Student Lans (NDSL), and Natinal Defense Student Lans (Defense Lans). The Teacher Educatin Assistance fr Cllege and Higher Educatin (TEACH) Grant Prgram prvides grants t students wh agree t teach full time fr at least fur years in high-need fields in lw-incme elementary r secndary schls as a cnditin fr receiving the grant funds. If a TEACH Grant recipient des nt cmplete the required teaching service within eight years after cmpleting the prgram f study fr which the TEACH Grant was received, the TEACH Grant funds are cnverted t a Direct Unsubsidized Lan that the grant recipient must repay in full, with interest, t the U.S. Department f Educatin. The hlder f yur FFEL Prgram lan(s) may be a lender, a guaranty agency, r the U.S. Department f Educatin. The hlder f yur Perkins Lan Prgram lan(s) may be a schl yu attended r the U.S. Department f Educatin. The hlder f yur Direct Lan Prgram lan(s) and/r yur TEACH Grant Agreement t Serve (if yu received a TEACH Grant) is the U.S. Department f Educatin. Yur lan hlder may use a servicer t handle billing and ther matters related t yur lan. The term hlder as used n this applicatin means either yur lan hlder r, if applicable, yur lan servicer. The term state fr purpses f the physician s certificatin in Sectin 4 (the physician must be licensed t practice in a state) includes the 50 United States, the District f Clumbia, American Sama, the Cmmnwealth f Puert Ric, Guam, the U.S. Virgin Islands, the Cmmnwealth f the Nrthern Mariana Islands, the Republic f the Marshall Islands, the Federated States f Micrnesia, and the Republic f Palau. A representative is a member f yur family, yur attrney, a law firm r legal aid sciety, r anther individual r rganizatin authrized t act n yur behalf in cnnectin with yur ttal and permanent disability discharge applicatin. SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (cntinues n next page) APPLYING FOR DISCHARGE (ALL APPLICANTS): 1. Submissin f discharge applicatin. After yu submit yur cmpleted discharge applicatin and any required dcumentatin t us, we will send yu a ntice that will: Acknwledge receipt f yur applicatin; Explain the prcess fr ur review f ttal and permanent disability discharge applicatins; and Infrm yu that yur lan hlders will suspend cllectin activity r cntinue the previus suspensin f cllectin activity n yur lans while we review yur applicatin fr discharge (yu are nt required t make any payments n yur lans during this perid). 2. Cnsequences f failure t submit discharge applicatin. If yu d nt submit an applicatin fr ttal and permanent disability discharge t us within 120 days f ntifying us that yu intend t submit an applicatin, cllectin activity will resume n yur lans, and yur lan hlder may capitalize any unpaid interest that accrued during the 120-day perid. This means that the unpaid interest will be added t the principal balance f yur lans, and interest will then be charged n the increased lan principal amunt. Hwever, if yu have a FFEL Prgram lan and the lan hlder is a guaranty agency, r if yu have a Federal Perkins Lan, unpaid interest will nt be capitalized at the end f the 120-day perid. Page 4 f 7

14 SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (cntinued) DISCHARGE PROCESS FOR VETERANS WHO HAVE BEEN DETERMINED BY THE VA TO BE UNEMPLOYABLE DUE TO A SERVICE-CONNECTED DISABILITY: 1. Our review f yur discharge applicatin. We will review the dcumentatin frm the VA t determine if yu are ttally and permanently disabled as described in paragraph (2) f the definitin f ttal and permanent disability in Sectin 5 f this applicatin. 2. Determinatin f eligibility r ineligibility fr discharge. If we determine that yu are ttally and permanently disabled, yu will be ntified that yur lans and/r TEACH Grant service bligatin has been discharged. The discharge will be reprted t natinwide cnsumer reprting agencies, and any lan payments received n yur lan n r after the effective date f the determinatin by the VA that yu are unemplyable due t a service-cnnected disability will be refunded t the persn wh made the payments. If we determine that yu are nt ttally and permanently disabled, yu will be ntified f that determinatin. The ntificatin will include: The reasn r reasns fr the denial f yur discharge applicatin; An explanatin that yur lans are due and payable t the lan hlder under the terms f the prmissry nte that yu signed and that yur lans will return t the status they were in at the time yu applied fr a ttal and permanent disability discharge; An explanatin that yur lan hlder will ntify yu f the date yu must resume making payments n yur lans; and An explanatin that if yu applied fr a discharge f a TEACH Grant service bligatin, yu must cmply with all terms and cnditins f yur TEACH Grant Agreement t Serve. The ntificatin will als explain yur ability t request recnsideratin f this determinatin r t submit a new discharge applicatin: Yu may request that we re-evaluate yur discharge applicatin if, within 12 mnths f the date f the ntificatin frm us that yu are ineligible fr discharge, yu prvide us with additinal dcumentatin frm the VA that supprts yur eligibility fr discharge (yu d nt have t submit a new applicatin); r If the dcumentatin frm the VA des nt indicate that yu are unemplyable due t a service-cnnected disability, yu may reapply fr discharge under the Discharge Prcess Fr All Other Applicants, as described belw (yu must submit a new applicatin with the required dcumentatin frm the SSA r a physician s certificatin in Sectin 4). DISCHARGE PROCESS FOR ALL OTHER APPLICANTS: 1. Our review f yur discharge applicatin. If yu submit a discharge applicatin supprted by an award f benefits ntice frm the SSA r an SSA Benefits Planning Query (BPQY), we will review the SSA ntice f award (r BPQY) t determine if it meets the requirements described in Sectin 2, Item 2 f this frm. If yu submit a discharge applicatin supprted by a physician s certificatin in Sectin 4 f this applicatin, we will review the physician s certificatin and any accmpanying dcumentatin t determine if yu are ttally and permanently disabled as described in paragraph (1) f the definitin f ttal and permanent disability in Sectin 5 f this applicatin. We may als cntact yur physician fr additinal infrmatin, r may arrange fr an additinal review f yur cnditin by an independent physician at ur expense. Based n the results f this review, we will determine yur eligibility fr discharge. If we determine during ur review f yur applicatin that yu received a Direct Lan r Perkins Lan prgram lan, r a TEACH Grant befre the date we received the SSA ntice f award (r BPQY) r befre the date the physician certified yur applicatin in Sectin 4, and a disbursement f that lan r grant is made after that date, but befre we have granted a discharge, we will suspend prcessing f yur discharge request until yu ensure that the full amunt f the disbursement is returned t the lan hlder r (fr a TEACH Grant) t us. If yu apply fr a ttal and permanent disability discharge and we determine as part f its review that a new Direct Lan r Perkins Lan prgram lan r a new TEACH Grant was made t yu n r after the date we received the SSA ntice f award (r BPQY) r the date the physician certified yur applicatin in Sectin 4, and befre the date we grant a discharge, we will deny yur discharge request. Cllectin will resume n yur lans and yu will again be respnsible fr cmplying with the terms and cnditins f yur TEACH Grant Agreement t Serve. 2. Determinatin f eligibility r ineligibility fr discharge. If we determine that yu are ttally and permanently disabled, we will ntify yu that a discharge has been apprved, and that yu will be subject t a pst-discharge mnitring perid fr three years beginning n the discharge date. The ntificatin f discharge will explain the terms and cnditins under which we will reinstate yur bligatin t repay yur lan r t cmplete yur TEACH service, as described in Item 3, belw. The discharge will be reprted t natinwide cnsumer reprting agencies, and any lan payments that were received after the date we received the SSA ntice f award fr SSDI r SSI benefits (r BPQY) r after the date the physician certified yur discharge applicatin will be returned t the persn wh made the payments. If we determine that yu are nt ttally and permanently disabled, we will ntify yu f that determinatin. The ntificatin will include: The reasn r reasns fr the denial f yur discharge applicatin; An explanatin that yur lans are due and payable t the lan hlder under the terms f the prmissry nte that yu signed and that yur lans will return t the status that wuld have existed if yur ttal and permanent disability discharge applicatin had nt been received; An explanatin that yur lan hlder will ntify yu f the date yu must resume making payments n yur lans; An explanatin that if yu applied fr a discharge f a TEACH Grant service bligatin, yu must cmply with all terms and cnditins f yur TEACH Grant Agreement t Serve; An explanatin that yu are nt required t submit a new ttal and permanent disability discharge applicatin if, within 12 mnths f the date f ur ntificatin t yu that yu are ineligible fr discharge, yu prvide additinal infrmatin regarding yur disabling cnditin that supprts yur eligibility fr discharge, and yu request that we re-evaluate yur discharge applicatin; and An explanatin that if yu d nt request re-evaluatin f yur prir discharge applicatin within 12 mnths f the date f ur ntificatin f ineligibility fr discharge, and yu still wish t have us re-evaluate yur eligibility fr a ttal and permanent disability discharge, yu must submit a new ttal and permanent disability discharge applicatin t us. If yu request a re-evaluatin f yur ttal and permanent disability discharge applicatin r submit a new ttal and permanent disability discharge applicatin, as described abve, yur request must include new infrmatin regarding yur disabling cnditin that was nt prvided t us in cnnectin with yur prir applicatin fr discharge. Page 5 f 7

15 SECTION 6: DISCHARGE PROCESS / ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR DISCHARGE (cntinued) 3. Pst-discharge mnitring perid. If yu are granted a discharge, we will mnitr yur status during the 3-year pst-discharge mnitring perid that begins n the date the discharge is granted. We will reinstate the requirement fr yu t repay yur lans and/r cmplete yur TEACH Grant service if, at any time during r at the end f the pst-discharge mnitring perid, yu: Receive annual earnings frm emplyment that exceed the pverty guideline amunt (see Nte belw) fr a family f tw in yur state, regardless f yur actual family size; Receive a new lan under the Direct Lan Prgram r the Perkins Lan Prgram, r a new TEACH Grant; Receive a disbursement f a Direct Lan Prgram r Perkins Lan Prgram lan r a TEACH Grant that was initially disbursed prir t yur discharge date and yu fail t ensure that the disbursement is returned t the lan hlder r (fr a TEACH Grant) t us within 120 days f the disbursement date; r Receive a ntice frm the SSA indicating that yu are n lnger disabled r that yur cntinuing disability review will n lnger be the 5- t 7-year perid indicated in the SSA ntice f award fr SSDI r SSI benefits r BPQY. During the 3-year pst-discharge mnitring perid, yu (r yur representative) must: Prmptly ntify us f any changes in yur address r telephne number; Prmptly ntify us if yur annual earnings frm emplyment exceed the pverty guideline amunt fr a family f tw in yur state (see Nte belw), regardless f yur actual family size; Upn request, prvide us with dcumentatin f yur annual earnings frm emplyment, n a frm that we will prvide; and Prmptly ntify us if yu receive a ntice frm the SSA indicating that yu are n lnger disabled r that yur cntinuing disability review will n lnger be the 5- t 7-year perid indicated in the SSA ntice f award fr SSDI r SSI benefits r BPQY (after yu had been previusly determined t be disabled by the SSA, were receiving SSDI r SSI benefits, and had a cntinuing disability review perid f 5 t 7 years r mre frm the date f yur last SSA disability determinatin). Nte: The pverty guideline amunts are updated annually and may be btained at We will ntify yu f the current pverty guideline amunts during each year f the pst-discharge mnitring perid. 4. Reinstatement f bligatin t repay discharged lans r cmplete discharged TEACH Grant service bligatin. If yu d nt meet the requirements described abve in Item 3 at any time during r at the end f the pst-discharge mnitring perid, we will reinstate yur bligatin t repay yur lans and/r t cmplete yur TEACH Grant service. If yur lans are reinstated, yu will be respnsible fr repaying yur lans t us in accrdance with the terms f yur prmissry nte(s). Yur lans will be returned t the status that wuld have existed if we had nt received yur ttal and permanent disability discharge applicatin. Hwever, yu will nt be required t pay interest n yur lans fr the perid frm the date f the discharge until the date yur repayment bligatin was reinstated. We will be yur lan hlder. If yur TEACH Grant service bligatin is reinstated, yu will again be subject t the requirements f yur TEACH Grant Agreement t Serve. If yu d nt meet the terms f that agreement and the TEACH Grant funds yu received are cnverted t a Direct Unsubsidized Lan, yu must repay that lan in full, and interest will be charged frm the date(s) that the TEACH Grant funds were disbursed. If yur bligatin t repay yur lans r t cmplete yur TEACH Grant service is reinstated, we will ntify yu f the reinstatement. This ntificatin will include: The reasn r reasns fr the reinstatement; Fr lans, an explanatin that the first payment due date n the lan fllwing the reinstatement will be n earlier than 60 days fllwing the date f the ntificatin f reinstatement; and Infrmatin n hw yu may cntact us if yu have questins abut the reinstatement, r if yu believe that yur bligatin t repay a lan r cmplete TEACH Grant service was reinstated based n incrrect infrmatin. SECTION 7: ELIGIBILITY REQUIREMENTS TO RECEIVE FUTURE LOANS OR TEACH GRANTS FOR VETERANS WHO RECEIVE A TOTAL AND PERMANENT DISABILITY DISCHARGE BASED ON A DETERMINATION BY THE VA THAT THEY ARE UNEMPLOYABLE DUE TO A SERVICE-CONNECTED DISABILITY: If yu are a veteran wh is granted a discharge based n a determinatin that yu are ttally and permanently disabled as described in paragraph (2) f the definitin f ttal and permanent disability in Sectin 5 f this applicatin, yu are nt eligible t receive future lans under the Direct Lan Prgram r the Perkins Lan Prgram, r future TEACH Grants, unless: Yu btain a certificatin frm a physician that yu are able t engage in substantial gainful activity; and Yu sign a statement acknwledging that the new lan r TEACH Grant service bligatin cannt be discharged in the future n the basis f any injury r illness present at the time the new lan r TEACH Grant is made, unless yur cnditin substantially deterirates s that yu are again ttally and permanently disabled. FOR ALL OTHER INDIVIDUALS WHO RECEIVE A TOTAL AND PERMANENT DISABILITY DISCHARGE: If yu are granted a discharge based n a determinatin that yu are ttally and permanently disabled in accrdance with paragraph (1) f the definitin f ttal and permanent disability in Sectin 5 f this applicatin, yu are nt eligible t receive future lans under the Direct Lan Prgram r the Perkins Lan Prgram, r future TEACH Grants, unless: Yu btain a certificatin frm a physician that yu are able t engage in substantial gainful activity; Yu sign a statement acknwledging that the new lan r TEACH Grant service bligatin cannt be discharged in the future n the basis f any injury r illness present at the time the new lan r TEACH Grant is made, unless yur cnditin substantially deterirates s that yu are again ttally and permanently disabled; and If yu request a Direct Lan Prgram r Perkins Lan Prgram lan, r a new TEACH Grant, within three years f the date that a previus lan r TEACH Grant was discharged, yu resume payment n the previusly discharged lan r acknwledge that yu are nce again subject t the terms f the TEACH Grant Agreement t Serve befre receiving the new lan. Page 6 f 7

16 SECTION 8: IMPORTANT NOTICES Privacy Act Ntice. The Privacy Act f 1974 (5 U.S.C. 552a) requires that the fllwing ntice be prvided t yu: The authrities fr cllecting the requested infrmatin frm and abut yu are 421 et seq., 451 et seq., 461 et seq., and 420L et seq. f the Higher Educatin Act f 1965, as amended (the HEA) (20 U.S.C et seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa et seq., and 20 U.S.C. 1070g et seq.) and the authrities fr cllecting and using yur Scial Security Number (SSN) are 428B(f) and 484(a)(4) f the HEA (20 U.S.C (f) and 1091(a)(4)) and 31001(i)(1) f the Debt Cllectin Imprvement Ac t f 1996 (31 U.S.C. 7701(c)). Participating in the Federal Family Educatin Lan (FFEL) Prgram, the W illiam D. Frd Federal Direct Lan (Direct Lan) Prgram, the Federal Perkins Lan (Perkins Lan) Prgram, and/r the Teacher Educatin Assistance fr Cllege and Higher Educatin (TEACH) Grant Prgram and giving us yur SS N are vluntary, but yu must prvide the requested infrmatin, including yur SSN, t participate. The principal purpses fr cllecting the infrmatin n this frm, including yur SSN, are t verify yur identity, t deter mine yur eligibility t receive a FFEL, Direct Lan, and/r Perkins Lan prgram lan r a TEACH Grant, t receive a benefit n a lan (such as a deferment, frbearance, discharge, r fr giveness) r a discharge f a TEACH Grant service bligatin, t permit the servicing f yur lan(s) r TEACH Grant(s), and, if it becmes necessary, t lcate yu and t cllect and reprt n yur lan(s) if yur lan(s) becme delinquent r in default. We als use yur SSN as an accunt identifier and t permit yu t access yur accunt infrmatin electrnically. The infrmatin in yur file may be disclsed, n a case-by-case basis r under a cmputer matching prgram, t third parties as authrized under rutine uses in the apprpriate systems f recrds ntices. Fr a lan r fr a TEACH Grant that has nt been cnverted t a Direct Unsubsidized Lan, the rutine uses f the infrmatin that we cllect abut yu include, but are nt limited t, its disclsure t federal, state, r lcal agencies, t institutins f higher educatin, and t third party servicers t determine yur eligibility t receive a lan r a TEACH Grant, t investigate pssible fraud, and t verify cmpliance with federal student financial aid prgram regulatins. In the event f litigatin, we may send recrds t the Department f Justice, a curt, adjudicative bdy, cunsel, party, r witness if the disclsure is relevant and necessary t the litigatin. If this infrmatin, either alne r with ther infrmatin, indicates a ptential vilatin f law, we may send it t the apprpriate authrity fr actin. We may send infrmatin t members f Cngress if yu ask them t help yu with federal student aid questins. In circumstances invlving emplyment cmplaints, grievances, r disciplinary actins, we may disclse relevant recrds t adjudicate r investigate the issues. If prvided fr by a cllective bargaining agreement, we may disclse recrds t a labr rganizatin recgnized under 5 U.S.C. Chapter 71. Disclsures may be made t ur cntractrs fr the purpse f perfrming any prgrammatic functin that requires disclsure f recrds. Befre making any such disclsure, we will require the cntractr t ma intain Privacy Act safeguards. Disclsures may als be made t qualified researchers under Privacy Act safeguards. Fr a lan, including a TEACH Grant that has been cnverted t a Direct Unsubsidized Lan, the rutine uses f this infrmatin als include, but are nt limited t, its disclsure t federal, state, r lcal agencies, t private parties such as relatives, present and frmer emplyers, business and persnal assciates, t creditrs, t financial and educatinal institutins, and t guaranty agencies t verify yur identity, t determine yur prgram eligibility and benefits, t permit making, servicing, assigning, cllecting, adjusting, r discharging yur lan(s), t enfrce the terms f the lan(s), t investigate pssible fraud and t verify cmpliance with fe deral student financial aid prgram regulatins, t lcate yu if yu becme delinquent in yur lan payments r if yu default, r t verify whether yur debt qualifies fr discharge r cancellatin. T prvide default rate calculatins, disclsures may be made t guaranty agencies, t financial and educatinal institutins, r t federal, state r lcal agencies. T prvide financial aid histry infrmatin, disclsures may be made t educatinal institutins. T assist prgram administratrs with tracking refunds and cancellatins, disclsures may be made t guaranty agencies, t financial and educatinal institutins, r t federal r state agencies. T prvide a standardized methd fr educatinal institutins t efficiently submit student enrllment status, disclsures may be made t guaranty agencies r t financial and educatinal institutins. T cunsel yu in repayment effrts, disclsures may be made t guaranty agencies, t financial and educatinal institutins, r t federal, state, r lcal agencies. Paperwrk Reductin Ntice. Accrding t the Paperwrk Reductin Act f 1995, n persns are require d t respnd t a cllectin f infrmatin unless it displays a currently valid OMB cntrl number. Public reprting burden fr this cllectin f infrmatin is estimated t average 0.5 hurs (30 minutes) per respnse, including the time fr reviewing instructins, searching existing data resurces, gathering and maintaining the data needed, and cmpleting and reviewing the infrmatin cllectin. Individuals are bligated t respnd t this cllectin t btain a benefit in accrdance with 34 CFR (b) r (c), 34 CFR (c)(2) r (c)(9), 34 CFR (b) r (c), and 34 CFR (b). Send cmments regarding the burden estimate(s) r any ther aspect f this cllectin f infrmatin, including suggestins fr re ducing this burden, t the U.S. Department f Educatin, 400 Maryland Avenue, SW, Washingtn, DC , r ICDcketMgr@ed.gv and reference OMB Cntrl Number IMPORTANT: D NOT return the cmpleted Discharge Applicatin t this address. If yu return the cmpleted frm t this address, it will delay the prcessing f yur applicatin. If yu have cmments r cncerns regarding the status f yur individual submissin f this frm, cntact the U.S. Department f Educatin at Page 7 f 7

17 BLANK DISCHARGE APPLICATION

18 OMB N Frm Apprved Exp. Date 6/30/2016 TPD-APP DISCHARGE APPLICATION: TOTAL AND PERMANENT DISABILITY IMPORTANT INFORMATION William D. Frd Federal Direct Lan Prgram Federal Family Educatin Lan Prgram Federal Perkins Lan Prgram TEACH Grant Prgram READ THIS FIRST This is an applicatin fr a ttal and permanent disability discharge f yur William D. Frd Federal Direct Lan (Direct Lan) Prgram, Federal Family Educatin Lan (FFEL) Prgram, and/r Federal Perkins Lan (Perkins Lan) Prgram lan(s), and/r yur Teacher Educatin Assistance fr Cllege and Higher Educatin (TEACH) Grant Prgram service bligatin. Yu nly need t submit a single applicatin t the U.S. Department f Educatin t apply fr discharge f all f yur Direct Lan, FFEL, and/r Perkins Lan prgram lans and yur TEACH Grant service bligatins. Thrughut this applicatin, the wrds we, us, and ur refer t the U.S. Department f Educatin. T qualify fr this discharge, yu must meet ne f the fllwing requirements: 1. Yu are a veteran wh has been determined by the U.S. Department f Veterans Affairs (VA) t be unemplyable due t a servicecnnected disability, and yu prvide dcumentatin frm the VA f that determinatin; OR 2. Yu have received a Scial Security Administratin (SSA) ntice f award fr Scial Security Disability Insurance (SSDI) r Supplemental Security Incme (SSI) stating that yur next scheduled disability review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin, and yu prvide a cpy f that SSA ntice f award. OR 3. Yu prvide a certificatin frm a physician in Sectin 4 f this Discharge Applicatin that yu are unable t engage in any substantial gainful activity (see definitin in Sectin 5) by reasn f a medically determinable physical r mental impairment that: Can be expected t result in death; Has lasted fr a cntinuus perid f nt less than 60 mnths; r Can be expected t last fr a cntinuus perid f nt less than 60 mnths. If yu d nt meet requirement #1 r requirement #2, yu may qualify fr discharge by btaining a certificatin frm a physician in Sectin 4 f this applicatin, as described abve fr requirement #3. If yu can prvide the dcumentatin t shw that yu meet requirement #1 r #2 abve, yu are nt required t have a physician cmplete Sectin 4. If yu are a veteran applying fr discharge under requirement #1, yu must prvide dcumentatin frm the VA shwing that the VA has determined that yu are unemplyable due t a service-cnnected disability. Yu d nt meet this requirement if yur disability is nt servicecnnected. The fllwing tw types f VA determinatins meet this requirement: (1) a determinatin that yu have a service-cnnected disability (r disabilities) that is 100% disabling; r (2) a determinatin that yu are ttally disabled based n an individual unemplyability determinatin. If yu are applying fr discharge under requirement #2, the SSA ntice f award that yu prvide must shw that yur next scheduled disability review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin. Yu d nt meet this requirement if the ntice f award states that yur next scheduled disability review will be within less than 5 years. If the ntice f award des nt clearly state the date f yur next scheduled review, cntact the SSA ffice that issued the award and request a Benefits Planning Query (BPQY). The BPQY prvides a summary f yur SSA disability benefits, including the scheduled date fr yur next disability review. If yur BPQY shws that yur next scheduled review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin, yu may submit a cpy f yur BPQY t shw that yu meet requirement #2. If yu are granted a discharge based n requirement #2 r requirement #3, we will mnitr yur status during a 3-year pst-discharge mnitring perid. Yur discharged lans r TEACH Grant service bligatin may be reinstated if yu d nt meet certain requirements during this perid, as explained in Sectin 6 f this frm. Except fr VA r SSA determinatins as described abve (requirements #1 and #2), a disability determinatin by anther federal r state agency des nt qualify yu fr this discharge. Lan amunts discharged due t ttal and permanent disability may be cnsidered taxable incme by the Internal Revenue Service (IRS). Cntact the IRS fr mre infrmatin. If yu wish t designate an individual r rganizatin t represent yu in matters related t yur ttal and permanent disability discharge request, yu must cmplete the Ttal and Permanent Disability: Applicant Representative Designatin frm. Yu may btain this frm frm ur Ttal and Permanent Disability Discharge Servicer (see belw fr cntact infrmatin). Befre submitting yur applicatin, make sure that Sectin 3 and (if required) Sectin 4 include all requested infrmatin. Incmplete r inaccurate infrmatin may cause yur applicatin t be delayed r rejected. WHERE TO SEND YOUR COMPLETED DISCHARGE APPLICATION Send yur cmpleted applicatin with any required dcumentatin (see the instructins in Sectin 2 n page 2) t the fllwing address: U.S. Department f Educatin TPD Servicing PO Bx Lincln, NE If yu need help cmpleting this frm, cntact ur Ttal and Permanent Disability Discharge Servicer: Phne: disabilityinfrmatin@nelnet.net Web site: Page 1 f 7

19 OMB N Frm Apprved Exp. Date 6/30/2016 DISCHARGE APPLICATION: TOTAL AND PERMANENT DISABILITY William D. Frd Federal Direct Lan, Federal Family Educatin Lan, Federal Perkins Lan, and TEACH Grant Prgrams WARNING: Any persn wh knwingly makes a false statement r misrepresentatin n this frm r n any accmpanying dcuments will be subject t penalties that may include fines, imprisnment, r bth, under the U.S. Criminal Cde and 20 U.S.C SECTION 1: APPLICANT IDENTIFICATION Please enter r crrect the fllwing infrmatin. Check this bx if any f yur infrmatin has changed. SSN - - DOB - - Name Address City, State, Zip Cde Telephne ( ) SECTION 2: INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION Address (Optinal) Carefully read the entire applicatin, including page 1, the instructins in this sectin, and the additinal infrmatin n the fllwing pages. Type r print in dark ink. Sign and date the applicatin in Sectin 3. If yu are required t have a physician cmplete Sectin 4, enter yur name and Scial Security Number at the tp f page 2 (if nt preprinted). Send the cmpleted applicatin with any required dcumentatin t: U.S. Department f Educatin, TPD Servicing, PO Bx 87130, Lincln, NE Are yu a veteran wh has received a determinatin frm the U.S. Department f Veterans Affairs (VA) that yu are unemplyable due t a servicecnnected disability? Yes Attach dcumentatin f the VA determinatin and cmplete Sectin 3. Yu are nt required t have a physician cmplete Sectin 4. N Cntinue t Item Have yu received an SSA ntice f award fr SSDI r SSI benefits r an SSA Benefits Planning Query (BPQY) stating that yur next scheduled disability review will be 5 t 7 years r mre frm the date f yur last SSA disability determinatin? Yes Attach a cpy f the SSA ntice f award r BPQY and cmplete Sectin 3. Yu are nt required t have a physician cmplete Sectin 4. N Cmplete Sectin 3 and have a physician wh is a dctr f medicine r stepathy cmplete and sign Sectin 4. Yu must submit this applicatin t us within 90 days f the date f yur physician s signature in Sectin 4. SECTION 3: APPLICANT S DISCHARGE REQUEST, AUTHORIZATION, UNDERSTANDINGS, AND CERTIFICATIONS I request that the U.S. Department f Educatin discharge my Direct Lan, FFEL, and/r Perkins Lan, prgram lan(s), and/r my TEACH Grant service bligatin. I authrize any physician, hspital, r ther institutin having recrds abut the disability that is the basis fr my request fr a discharge t make infrmatin frm thse recrds available t the U.S. Department f Educatin. I understand that: (1) If I am applying fr discharge based n a physician s certificatin in Sectin 4, I must submit this applicatin t the U.S. Department f Educatin within 90 days f the date f my physician s signature in Sectin 4. (2) Unless I am a veteran wh prvides the dcumentatin described abve in Sectin 2, Item 1, I may be required t repay a discharged lan r satisfy a discharged TEACH Grant service bligatin if I fail t meet certain requirements during a pst-discharge mnitring perid, as explained in Sectin 6. (3) If I am a veteran wh des nt meet the requirement described abve in Sectin 2, Item 1, and I have btained a certificatin frm a physician in Sectin 4, the certificatin by the physician n this frm is nly fr the purpses f establishing my eligibility t receive a discharge f a Direct Lan Prgram lan, a FFEL Prgram Lan, a Perkins Lan Prgram lan, and/r a TEACH Grant service bligatin, and is nt fr purpses f determining my eligibility fr, r the extent f my eligibility fr, VA benefits. (4) If I wish t designate an individual r rganizatin t represent me in matters related t my ttal and permanent disability discharge request, I must cmplete and submit the Ttal and Permanent Disability Discharge: Applicant Representative Designatin frm. I certify that: (1) I have a ttal and permanent disability, as defined in Sectin 5; and (2) I have read and understand the infrmatin n the discharge prcess, the terms and cnditins fr discharge, and the eligibility requirements t receive future lans r TEACH Grants as explained in Sectins 6 and 7. Signature f Applicant r Applicant s Representative (see NOTE belw) Date Printed Name f Representative (if applicable) NOTE: Yu may designate an individual r rganizatin t represent yu in matters related t yur ttal and permanent disability discharge request. If yu wish t designate a representative, yu must cmplete the Ttal and Permanent Disability: Applicant Representative Designatin frm. Yu may btain this frm frm ur Ttal and Permanent Disability Discharge Servicer. See the Read This First sectin f this frm fr cntact infrmatin. Page 2 f 7