Instructions for Borrower: Before signing this form‚ carefully read the following page. A representative may sign this form on your behalf if you are unable to do so because of your disability. Have Section 3 completed and signed by a doctor of medicine or osteopathy. Return the completed form to the address shown in Section 6. Note: If the loans that you want to have canceled are held by more than one loan holder‚ you must submit a separate copy of this certified cancellation request to each holder. Each copy must contain original signatures from you (or your representative) and the physician who completes Section 3.

Borrower Request‚ Authorizations‚ Understandings‚ and Certifications

I authorize any physician‚ hospital‚ or other institution having records about the disability for which I am requesting a cancellation of loan payments to make information from these records available to the holder of my loan(s).

I understand that this cancellation request will not be granted unless (1) off applicable sections of this form are completed‚ and (2) all additional requested documentation is provided. I further understand that I must submit a separate cancellation request to each holder of the loans that I want fo have canceled. It I am a veteran‚ I understand that the certification by a physician on this form is only for the purposes of establishing my eligibility to receive a cancellation of a FFEI Program or Direct Loan Program loan and Is not for purposes of determining my eligibility for or the extent of my eligibility for Department of Veterans Affairs benefits.

I certify that I have read‚ understand‚ and meet the eligibility criteria in Section 4 for cancellation due to total and permanent disability.

Instructions for Physician: The borrower identified above is applying for cancellation of his/her student loan obligation(s) based on total and permanent disability. You are being asked to complete this form to certify that the borrower is totally and permanently disabled. Note: The standard for determining disability for cancellation of the borrower’s loan obligation may be different from standards used under other public and private programs In connection with occupational disability or eligibility for social service benefits. Refer to the definition of Total and Permanent Disability in Section 4 on the following page. You may complete and sign this form only if you are a doctor of medicine or osteopathy legally authorized to practice in a state. Provide all requested information; you may attach additional pages if necessary. Please type or print in dark Ink. Sign the certification (a signature stamp is not acceptable) only if the borrower’s condition meets the definition of Total and Permanent Disability in Section 4.

Return the completed form to the borrower or the borrower’s representative.

• When did the borrower’s disabling condition begin? (MM–DD–YYYY) ____ _____| ____ ____ | _____ ______ _____ _____

• The borrower became unable to work and earn money or go to school on (MM–DD–YYYY) ____ _____| ____ ____ | _____ ______ _____ _____
  and the disabling condition is expected to continue indefinitely or result in death.

• Diagnosis of borrower’s present medical condition – specify the nature‚ duration and severity of the borrower’s present and future impairments:

I certify that‚ in my best professional judgement‚ the borrower Identified above is unable to work and earn money or go to school because of an injury or illness that is expected to continue indefinitely or result in death. I understand that any borrower able currently or in the future to work and earn money or go to school‚ even on a limited basis‚ is not considered to have a Total and Permanent Disability.

I am a (check one) ____ doctor of medicine ____ doctor of osteopathy legally authorized to practice in the state of __________________________and my professional license number Issued by that state is _____________________.

Definitions

• The Federal Family Education Loan (FFEL) Program includes Federal Stafford Loans (both subsidized and unsubsidized)‚ Federal Supplemental Loans for Students (SLS)‚ Federal PLUS Loans‚ and Federal Consolidation Loans.

• The William D. Ford Federal Direct Loan ’Direct Loan) Program includes Federal Direct Stafford/Ford Loans (Direct Subsidized Loans)‚ Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans)‚ Federal Direct PLUS Loans (Direct PLUS Loans)‚ and Federal Direct Consolidation Loans (Direct Consolidation Loans).

• The holder of a borrower’s FFEL Program loans) may be a lender‚ a guaranty agency‚ or the U.S. Department of Education (the Department). The holder of a borrower’s Direct Loan Program loans) is the Department.

• Cancellation due to a total and permanent disability condition cancels a borrower’s obligation to repay the remaining outstanding principal and accrued Interest on a FFEL Program and/or Direct Loan Program loan.

• Total and Permanent Disability means that a borrower must be unable to work and earn money or go to school because of an Injury or illness that is expected to continue Indefinitely or result in death. Note: This standard may be different from standards used under other private and public programs in connection with occupational disability or eligibility for social service benefits.

Borrower Eligibility Criteria

• You must be unable to work and earn money or go to school because of an injury or illness that Is expected to continue indefinitely or result in death.
  If you are able–currently or in the future–to work and earn money or go to school‚ even on a limited basis‚ you are not eligible for a loan cancellation based on Total and Permanent Disability.

• Your cancellation may not be based on a condition that existed at the time you applied for your loan(a) unless the condition has since substantially deteriorated so that you are now totally and permanently disabled.

• For Consolidation Loans‚ your condition may not have existed before you applied for each of the loans which were consolidated‚ unless your condition has since substantially deteriorated so that you are now totally and permanently disabled. You must provide to the holder of your loan(s) the disbursement dates of the underlying loans If the condition did exist prior to the date the underlying loans were made.

• If you are granted a cancellation due to total and permanent disability‚ you are not eligible for future student loans unless you (1) obtain a certification from a physician that you are able to engage in substantial gainful activity‚ and (2) acknowledge in writing that the new loan cannot be canceled on the basis of any condition present when the loan is made‚ unless that condition substantially deteriorates.

Privacy Act Disclosure Notice: The Privacy Act of 1974 (5 U.S.C. 552a) requires that we disclose to you the following Information:

The authorities for collecting this Information are ¤428(b)(2)(A) et seq. and ¤451 et seq. of the Higher Education Act of 1965‚ as amended (the HEA) (20 U.S.C. ¤1078(b)(2)(a) et seq. and 61087a et seq.) The principal purpose for collecting this Information is to determine whether you are eligible for a cancellation of your loans) under the Federal Family education Loan (FFEL) Program and/or the William D. Ford Federal Direct Loan (Direct Loan) Program.

We ask that you provide the information requested on this cancellation form on a voluntary basis. However‚’ you must provide all of the requested Information so that the holder(s) of your loan(s) can determine whether you qualify for a cancellation.

The Information In your file may be disclosed to third parties as authorized under routine uses In the Privacy Act notices called "Title IV Program Fil9s’’ (originally published on April 12 1994 Federal Register‚ Vol. 59‚ p. 17351) and "National Student Loan Data System" originally published on December 20‚ 1994‚ Federal Register Vol. 59 p. 65532). Thus‚ this information fray be disclosed to parties that we authorize to assist us In administering the Federal student aid programs‚ including contractors that are required to maintain safeguards under the Privacy Act Disclosures may also be made for verification of. Information‚ determination of eligibility‚ enforcement of conditions of the loan or grant‚ debt collection‚ and the prevention of fraud‚ waste‚ and abuse and these disclosures may be made through computer matching programs with other Fedora’ agencies. Disclosures may be made to determine the feasibility of entering into computer matching agreements. We may send information to members of Congress If you ask them in writing to help you with Federal student aid questions. If we are Involved In litigation‚ we may send information to the Department of Justice (DOJ)‚ a court‚ adjudicative body‚ counsel‚ or witness if the disclosure is related to financial aid and certain other conditions are met. If this Information‚ either alone or with other information‚ indicates a potential violation of law‚ we may send It to the appropriate authority for consideration of action and we may disclose to DOJ to get Its advice related to the Title IV‚ .. HEA programs or questions under the Freedom of Information Act. Disclosures may be made to qualified researchers under Privacy Act safeguards. In some circumstances involving employment decisions‚ grievances‚ or complaints of involving decisions regarding the letting of a contract or making of a grant‚ license‚ or other benefit‚ we may send information to an appropriate authority. In limited circumstances‚ we may disclose to a Federal labor organization recognized under 5 U.S.C. Chapter 71.

Because we request your social security number (SSN)‚ we must Inform you that we collect your SSN on a voluntary basis‚ but section 484(a)(4) of the HEA (20 U.S.C. ¤1091(a)(4)) provides that‚ in order to receive any grant‚ loan‚ or work assistance under Title IV of the HEA‚ a student must provide his or her SSN. Your SSN is used to verify your identity‚ and as an account number (identifier) throughout the life of your loans) so that data may be recorded accurately.

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 1845–0015. The time required to complete this information collection is estimated to average 0.5 hours (30 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. II 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 below.