REPAYMENT APPLICATION

INSTRUCTIONS
Under the Borrower Defense to Repayment provision of law, certain conduct by a school you attended might make you
eligible to receive a discharge of some or all of your federal student loans. The type of conduct that might make you
eligible for student loan relief and the process by which the Department of Education will review your claim may differ
based upon when you took out your loan. In general, loans taken out or consolidated prior to June 30, 2017 will be
evaluated under one set of regulations, while those taken or consolidated between July 1, 2017 and June 30, 2020 will
be evaluated under a second set of regulations, and those taken or consolidated after July 1, 2020 will be evaluated
under a third set of regulations. For that reason, in completing this application you may be asked different questions
about different loans or may receive a different determination regarding your eligibility for loans taken or consolidated at
different points in time.
The most common types of conduct that might make a borrower eligible for loan relief through borrower defense to
repayment discharge are misrepresentations of the truth made by the school or its representatives during their efforts
to recruit you to enroll at the school or to continue your enrollment at the school. These misrepresentations typically
take the form of untruthful representations of the school’s selectivity in admitting students, its rankings as compared to
other schools, the job placement and earnings outcomes of its prior graduates, or the likelihood that its credits will be
accepted by another school or that it will accept credits from other schools.
There are other kinds of experiences that may leave a student dissatisfied with their educational choices; however,
these experiences do not make a borrower eligible for federal student loan relief under the borrower defense to
repayment provision. Examples of such experiences that would likely not make a borrower eligible for relief include,
but are not limited to:
• Dissatisfaction with the school’s program or classes, the grades a student received, or the perceived teaching
skills of otherwise qualified instructors;
• Disappointment with the school’s housing or facilities, availability of on-campus housing, parking availability, the
performance of a school’s athletic teams, the availability of or access to student activities on campus, or campus
eating facilities, food quality or meal plans;
• A student’s inability to live in their dormitory of choice, enroll in the program of their choice *unless otherwise
guaranteed admission to the program), or the departure of a distinguished faculty member under whom the
student wished to study;
• Informal comments made by other students who are or in the past were enrolled at the school, but who are not
spokespeople for the school and are not participating in school-sponsored student recruitment activities;
• General findings of a school’s non-compliance with certain U.S. Department of Education’s rules for
administering Federal Aid;
• Violations of local, state, or federal laws unrelated to the making of a Federal student loan, such as those that
govern truth in advertising or misrepresentation;
• Personal injury, loss of property, sexual harassment or other violations of law or civil rights; or
• Academic disputes and disciplinary matters.
It is also important to understand that to be eligible for full or partial federal student loan relief through borrower defense
to repayment, you must also have suffered monetary harm. The act of taking a loan or holding student debt is not, by
itself, considered to be monetary harm. Instead, the Department compares earnings of prior graduates of your program
to graduates of other similar programs and makes a determination of monetary harm, if the earnings of graduates of your
program are below the range of normal variation of earnings among graduates of other similar programs. The data used
to calculate earnings for purposes of determining monetary harm are based on data provided by a Federal agency, such
as the Internal Revenue Service or in some instances, the Social Security Administration.
If you believe you are eligible for borrower defense to repayment relief, please complete this application.
When answering questions on this application, please be as detailed as possible. While you are not required to
submit documentation with your application to be considered for discharge, we recommend that you do so.

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SECTION 1: BORROWER INFORMATION
Please provide contact information for the borrower:
First Name Middle Name Last Name

Date of Birth (mm/dd/yyyy) Social Security Number Telephone Number
Email Address

Street Address City State Zip Code
Are you a PARENT who took out a federal loan on behalf of the student?
Yes No
If yes, please enter the full name of the student (Last, First, Middle):
If yes, please enter the student’s Social Security Number:
SECTION 2: SCHOOL INFORMATION
School Name:
Campus Name (if you attended a multi-campus system or school):
Campus Location (City, State):
In what state(s) did you live during the enrollment period that is the subject of this claim, and when did you live in each
state listed (month, year to month, year)?

Enrollment Dates at this school (month, year to month, year). (If you have multiple enrollments at the school, please list
all that are the subject of this claim):

Are you still enrolled at this school? Yes No
Did you enroll at the school subsequent to the enrollment which is the subject of this claim? If so, when?

Are the enrollment dates listed above approximate or exact? Approximate Exact

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Program Name or Major (e.g. Engineering, Law, Nursing).

Credential/Degree Sought (e.g. Certificate, Diploma, Associates, Bachelors, Masters).

If you are seeking relief for multiple programs, please submit a separate application for each program.
Current Enrollment Status at school listed above:
Graduated Transferred Out Withdrew Attending
Note: if you are enrolled at this school, indicate that you are “attending” even if at the time you complete this application
you are on a scheduled break, an approved leave of absence, or have decided to not attend classes during the current
term, but plan to resume attendance in the near future.
SECTION 3: OTHER REFUNDS, REMEDIES, LOAN REDUCTION OR TUITION RECOVERY
REQUESTS OR ACTIONS:
Have you made any attempt, other than submitting this application, to recover tuition or fees that you paid to your school
or to have your student loans forgiven (for example, submitting a closed school loan discharge application to the U.S.
Department of Education or seeking relief as part of a class action lawsuit or other settlement)?
Yes No
If yes, please describe these other request(s), and attach any documentation about the requests, if available.

Have you received financial relief as a result of any of these attempts? Yes No
If so, how much relief did you receive?
Have you been denied financial relief for any of the attempts you have made or that were made by others on your
behalf?
Yes No
If so, which ones and why?

Have you been, or are you currently in, arbitration with the school that is the subject of this application?
Yes No
If yes, what was the date that a written request for arbitration was filled, by either yourself or the school?

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Documentation: Please attach any relevant documents related to the arbitration:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation that you believe is related to the arbitration.
SECTION 4 – CONDUCT THAT RESULTS IN ELIGIBILITY FOR BORROWER DEFENSE TO
REPAYMENT RELIEF
ADMISSIONS SELECTIVITY
Did your school misrepresent or fail to tell you important information about their admissions practices or admissions
selectivity?
Examples of such behavior include, but are not limited to misrepresenting: the average grade point average or entrance
exam scores of current students; the percentage of applicants who were accepted by the school; the percentage of
applicants who submitted standardized test scores or met other admissions criteria; or the ranking of the school or
program relative to other schools or programs. Please select all that apply:
My school misrepresented the selectivity of the school, meaning the percentage of applicants who are admitted or
denied admission to the school or their qualifications (such as test scores, GPAs, or prior experience).
My school claimed to be an open-enrollment school, but failed to disclose that some programs are not open
enrollment and instead have entrance requirements, such as minimum GPA, test scores, or volunteer experience
in the field that limit admissions to the program.
My school made a misrepresentation concerning its criteria for admission, meaning the basis upon which a school
determines who it will admit.
My school made a misrepresentation concerning the ranking of the school or a program offered by the school.
Other, please identify:
Per item selected above:
Please describe your communication with the school. Please describe in detail what the school told you, or failed to tell
you, and why you believe it was a misrepresentation.

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Other, please identify:
Written brochures
TV advertisements
Over email
Over the phone
Online
In person
How did the school communicate with you about its admission process? Please select all that apply:

Please describe how the school communicated with you.
Per the item above selected:

Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?
Yes No

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation you believe supports your application.
Who at the school provided you with the allegedly misrepresented information? If known, please provide the names and
titles of these individuals.

When did you discover that the information that the school provided was inaccurate?

Please explain.

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REPRESENTATIONS TO THIRD PARTIES
Did your school provide misleading or incorrect data about the school’s admissions requirements, selectivity,
or student outcomes to an accreditor or an organization that ranks or rates schools of higher education?
Please select all that apply:
My school misrepresented information about itself or enrolled students to a ranking organization, such as U.S. News
and World Report or Barron’s Profile of American Colleges.
My school misrepresented information about itself or enrolled students to an accrediting agency.
My school misrepresented information about itself or enrolled students to a state higher education authorizing
agency such as the New York State Department of Education, Office of College and University Evaluation or the
Illinois Board of Higher Education.
My school misrepresented information about itself or enrolled students to a Federal agency, such as the U.S.
Department of Veterans Affairs or the the U.S. Department of Education.
Other, please identify:

Please explain:
When did you discover that the information that the school provided was inaccurate?

Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?
Yes No
Please explain.

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URGENCY TO ENROLL
Urgency to enroll is not itself a grounds for Borrower Defense to Repayment discharge, but can be considered
as evidence supporting the reasonableness of a borrower’s reliance on a misrepresentation. Thus applicants
completing this section must also make a separate allegation of school misconduct to be considered for
Borrower Defense to Repayment discharge.
Did your school tell you that you had to enroll right away (such as the same day you contacted or visited the school) or
you would miss out on an enrollment spot or scholarship opportunity?

Please describe how the school communicated with you.
Yes No
If so, was that false information?
Yes No
If yes, please explain.

Who at the school told you that you had to enroll on the spot or on the same day as your visit or inquiry? If known,
please provide their names and titles of these individuals.

Per item above selected:

When did you discover that the information that the school provided was inaccurate?

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Page 8 of 25

Please explain.

Please explain.
Yes No
Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities

Did the school misrepresent or fail to tell you important information about the availability of educational opportunities or
support services provided by the school? Please select all that apply:
EDUCATIONAL SERVICES

My school misrepresented the availability of internships or externships.
My school misrepresented the qualifications of its faculty.
My school misrepresented the services that would be provided by its career services staff or department.
My school misrepresented how my course of study would be taught (for example, ground-based versus online).
My school misrepresented the prerequisites required for my course of study.

My school told me I would be able to graduate in a certain amount of time, but then did not offer enough sections of
required classes so that I could complete the program on time.
Other, please identify:
My school misrepresented how often required courses would be available or when those courses would be
scheduled (i.e. you were promised you could complete the program by enrolling on weekends, and then you
learned that a required course was available only on weekdays during regular business hours when you are
working)
My school misrepresented the number of credits required to graduate.

Please describe how the school communicated with the school. Please describe in detail what the school told you, or
failed to tell you, and why you believe it was a misrepresentation.
Per item selected, above:

How did the school communicate with you about its educational services? Please select all that apply:
In person
Online
Over the phone
Over email
TV advertisements
Written brochures
Other, please identify:
Per item above selected:
Please describe how the school communicated with you.

Who at the school provided you with the allegedly misrepresented information? If known, please provide the names and
titles of these individuals.

When did you discover that the information that the school provided was inaccurate?

Please explain.

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Please explain.
Yes No
Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation you believe supports your application.

Did your school misrepresent employment outcomes that would be available to you or the employment outcomes of prior
graduates? Please select all that apply:
EMPLOYMENT PROSPECTS

My school did not fulfill its promise that I would find future employment.
My school misrepresented its job placement rates.
My school misrepresented the demand for graduates in my field.
My school misrepresented its partnerships with employers.
My school misrepresented my eligibility for a certification or a licensure in my field of study.
My school exaggerated the earnings of prior graduates or my likely earnings after graduation.
My school misrepresented that it was accredited when it was not.

Other, please identify:
My school misrepresented that my program had the accreditation necessary to qualify graduates for licensure or
certification when it did not.
My school failed to tell me that my programs did not have the accreditation necessary to qualify graduates for
certification or licensure.

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How did the school communicate with you about your employment prospects? Please select all that apply:
In person
Online
Over the phone
Over email
TV advertisements
Written brochures
Other, please identify:

Please describe how the school communicated with you.
Per item above selected:

Who at the school provided you with the allegedly misrepresented information? If known, please provide the names and
titles of these individuals.

Please provide information about the difficulties you have had getting a job in your field of study that lead you to believe
that the school misrepresented the employment outcomes or earnings of past graduates or your likely employment
outcomes or earnings.

When did you discover that the information that the school provided was inaccurate?

Please explain.

Yes No
Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?

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PROGRAM COST AND NATURE OF LOAN
Did the school mislead you, or fail to tell you, important information about your program cost or the nature of your loan?
Please select all that apply:
My school told me I was receiving only grants and scholarships, but I found out later that some or all of those funds
were loans.
My school offered me a payment plan without telling me that the plan would convert to a loan without accurately
disclosing the terms of the payment plan or resulting loan.

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My school misrepresented the repayment terms or total cost of loans it provided to me or that were provided to me
by a lender recommended by the school.

Other, please identify:
Please explain.

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation you believe supports your application.

My school misrepresented the overall cost of my program.
My school misrepresented what costs were or were not included in the published tuition and fees.
My school misrepresented the cost of living in campus-owned or campus-operated housing.
My school offered me a full scholarship when admitting me to the school, but then reduced the scholarship amount
or failed to renew the scholarship even though I met the requirements of the scholarship, such as by maintaining a
certain GPA, enrolling in a particular program, performing required community or volunteer service, or some other
criteria that I satisfied.

Please describe your communication with the school. Please describe in detail what the school told you, or failed to tell
you, and why you believe it was a misrepresentation.
Per item selected, above:

How did the school communicate with you about your program cost and the nature of your loan? Please select all that
apply:
In person
Online
Over the phone
Over email
TV advertisements
Written brochures
Other, please identify:
Per item above selected:
Please describe how the school communicated with you.

Who at the school provided you with the allegedly misrepresented information? If known, please provide the names and
titles of these individuals.

When did you discover that the information that the school provided was inaccurate?

Please explain.

Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?
Yes No
Please explain.

Page 13 of 25

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation you believe supports your application.
TRANSFERRING CREDITS
Did your school make a misrepresentation to you about the likelihood of credits earned at the school being accepted by
other schools as transfer credits or about its likelihood to give you transfer credit for courses or work experiences
completed elsewhere? Please select all that apply:
My school told me that my credits were transferrable to a specific school, but they were not.
My school told me credits earned at the school were generally transferrable to other schools, but they were not.
My school told me it would accept credits earned elsewhere if I enrolled, but then, after I enrolled, it told me that it
would not accept some or all of my transfer credits.
My school told me they would accept my credits, but did not inform me until after I enrolled that those credits would
not be counted toward my major.
Other, please identify:
Per item selected, above:
Please describe your communication with the school. Please describe in detail what the school told you, or failed to tell
you, and why you believe it was a misrepresentation.

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Per item above selected:
Please describe how the school communicated with you:

Who at the school provided you with the allegedly misleading information? If known, please provide the names and
titles of these individuals.

When did you discover that the information that the school provided was inaccurate?

Please explain:

Page 15 of 25

Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?
Yes No
Please explain.

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation you believe supports your application.
CAREER SERVICES
Did your school make a misrepresentation to you about the scope and availability of career services support it would
provide? Please select all that apply:
My school failed to provide the career services assistance it promised (including, but not limited to: resume writing
help, mock interviews, and responding to job listings)
My school promised that it would find me a job when I graduated but it did
Other, please identify:
Per item selected, above:
Please describe your communication with the school. Please describe in detail what the school told you, or failed to tell
you, and why you believe it was a misrepresentation.

Page 16 of 25

Per item selected, above:
Please describe how the school communicated with you:

Page 17 of 25

Who at the school provided you with the allegedly misrepresented information? If known, please provide the names and
titles of these individuals.

How were you financially affected by the misrepresentation?

When did you discover that the information that the school provided was inaccurate?

Please explain:

Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?
Yes No
Please explain:

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Any other documentation you believe supports your application.

Page 18 of 25

JUDGMENT
Note: This section only applies to borrowers who receive a Direct Loan, including a Direct Consolidation Loan, on or
after July 1, 2017 and prior to July 1, 2020.
Did you successfully file suit and obtain one or more nondefault, contested judgments against your school in a Federal or
State court or from a Federal or State administrative tribunal or did you benefit from a government enforcement action or
from a nondefault, contested judgment that arose from your participation in class action litigation?
Yes No
Have you received the full amount awarded in the judgment or judgments?
Yes No
If not, what is the outstanding balance of the judgment or judgments owed to you?

Please attach the judgment or judgments and all relevant documents relating to your judgment or judgments.
BREACH OF CONTRACT
Note: This section only applies to borrowers who receive a Direct Loan, including a Direct Consolidation Loan, on or
after July 1, 2017 and prior to July 1, 2020.
Did you ever enter into a contract with your school (e.g. enrollment agreement or other agreement)?
Yes No

Did your school fail to perform any obligations under the contract? For example, your school may have breached a
contract with you if they denied you the right to defend yourself against an accusation of a Title IX violation (sexual
advancement/misconduct) based on your school’s disciplinary policy.)
Yes No
If so, please provide a copy of the contract.
State when the school failed to perform any obligation(s) of that contract.
Please explain:

Provide a detailed description why you believe the school breached the contract.

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OTHER
Did your school make a misrepresentation to you, or fail to tell you, important information other than what you have
already alleged in this application?
Yes No
Please describe your communication with the school. Please describe in detail what the school told you, or failed to tell
you, and why you believe it was a misrepresentation.

How did the school communicate with you? Please select all that apply:
In person
Online
Over the phone
Over email
TV advertisements
Written brochures
Other, please identify:
Per item selected, above:
Please describe how the school communicated with you:

Who at the school provided you with the allegedly misrepresented information? If known, please provide the names and
titles of these individuals.

Page 20 of 25

When did you discover that the information that the school provided was inaccurate?

Please explain:

Was the alleged misrepresentation the basis of or pivotal to your decision to attend the school?
Yes No
Please explain:

Documentation: Please attach any relevant documents that support these allegations including:
• Transcripts
• Enrollment agreements
• Promotional materials from your school
• Communications with school officials or employees, or third party to which the information was reported
• Student Manual
• Course Catalog
• Legal documents
• Findings or determinations made by government entities
• Copies of the information that was reported to a third party and that you saw
• Any other documentation you believe supports your application.
SECTION 5: FINANCIAL HARM
Note: This section only applies to borrowers who receive a Direct Loan, including a Direct Consolidation Loan, on or
after July 1, 2020.
You are eligible to receive full or partial loan discharge as a result of an eligible borrower defense claim only if you have
suffered financial harm as a result of your school’s misrepresentation. We can only discharge federal student loans, and
the amount of a discharge that you may be eligible to receive cannot be more than what you borrowed. For example, we
cannot consider private student loans you may have borrowed. Financial harm does not include:
• Nonmonetary loss, such as personal injury, inconvenience, aggravation, emotional distress, pain
and suffering, punitive damages, or opportunity costs.
• The act of taking out a federal student loan or merely having federal student loan debt.
• Your voluntary decision to pursue less than full-time work.
• Your decision to not work.
• Your decision to voluntarily change occupations or pursue a different line of work.
• Payments you made other than through the use of federal student loans.

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Please note that you are not required to complete this field, and that the Department will not limit the amount you are
owed to the amount you reported in this field. The information you provide helps us review financial harm, but the
Department also considers published earnings information from prior graduates to determine whether or not you
were financially harmed, and how much harm you incurred. If you complete this field, you may, but are not required,
to include the amount of your federal student loans (the Department has this information already).
What is the total monetary loss associated with your federal student loans that you have incurred due to your school’s
alleged misrepresentation?

Please explain how you determined that amount:

For which jobs did the program say it would prepare you, if any?

When and how did the school provide you with this information?

Have you actively pursued employment in the field for which your education was intended to prepare you?
Yes No
If yes, list jobs in your field for which you applied, and the date on which you applied for each, as well as any
reason you may have been given for not being selected for that or those jobs. You may limit the list to jobs for
which you have applied during the most recent year.
Job Title Date Applied Reason for Not Being Selected for the Position

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If yes, please include documents that demonstrate this pursuit. These may include:
• Job application confirmation emails
• Correspondence with potential employers
• Registration at job fairs
• Enrolling with a job recruiter
• Attendance at a resume workshop

Have you failed to meet other requirements or qualifications for employment in your field of study for reasons unrelated
to your school’s misrepresentation such as, but not limited to, your ability to pass a drug test, satisfy driving record
requirements, or meet health qualifications?
Yes No
If yes, please explain:

SECTION 6: FORBEARANCE AND STOPPED COLLECTIONS
If you are not currently in default on any Federal student loan, you may request forbearance status on the Federal
student loans that are the subject of this application while your application is under review. “Forbearance” means that you
do not have to make loan payments, and your loans will not go into default, while your application for a borrower defense
discharge is pending with the U.S. Department of Education. Your servicer will notify you when your loans have been
placed into forbearance status.
If your Federal student loans are in default, you may request stopped collections status on the Federal student loans that
are the subject of this application while your application is under review. “Stopped collections status” means that the
Federal government or debt collection companies will not attempt to collect on the defaulted, including efforts to withhold
money from your wages or Federal income tax refunds, while your borrower defense application is pending with the U.S.
Department of Education.
If you have more questions about forbearance or stopped collections, visit StudentAid.gov/borrower-defense or contact
your servicer. If you do not know who your servicer is, please visit StudentAid.gov/aid-summary or call 1-800-4-FED-AID.
Interest will continue to accumulate on all Federal student loans regardless of their status, including subsidized loans. If
your application for borrower defense is denied or partially approved, the total amount you owe on those loans may be
higher, and outstanding interest may capitalize (meaning that they will be added to your principal balance). If you wish to
make interest payments while your loans are in a forbearance or stopped collections status, please contact your servicer.
You do not have to place your loans in forbearance or stopped collections to apply for borrower defense relief. Instead,
you may opt to continue making payments on your loans, especially if you are in a repayment program like loan
rehabilitation to remove your loans from default. If you received loans for attendance at a school for which you are not
filing a claim, you still must repay those loans.
You can learn more about repayment options at StudentAid.gov/manage-loans.
Are you in default on any Federal student loans?
If the answer is no, do you wish to request forbearance on the loan(s) for which you have filed a borrow defense
application?
Yes, to be placed in forbearance. No.
If your answer is yes, do you wish to request stopped collections status?
Yes No.
If you do not select one of the options above and you are not in default on any Federal student loan, the U.S.
Department of Education will automatically place the Federal student loan(s) into forbearance that is the subject of your
borrower defense application pending the Department’s review of the application.

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If you do not select one of the options set forth above and you are in default, the Department will place into stopped
collections status the Federal student loan(s) that is the subject of your borrower defense application pending the
Department’s review of the application.
The Department will also make these requests to commercial holders of Federal Family Education Loan (FFEL) program
loans not held by the Department.

SECTION 7. CERTIFICATION
By signing this attestation I certify that:
All of the information that I provided is true and complete to the best of my knowledge. Upon request, I agree to provide
to the U.S. Department of Education additional information that is reasonably available to me that will verify the accuracy
of my completed attestation.
I also agree to provide, upon request, testimony, a sworn statement, or other documentation reasonably available to me
that demonstrates to the satisfaction of the U.S. Department of Education or its designee that I meet the qualifications for
borrower defense.
I certify that I received proceeds of a federal loan, in whole or in part, to attend the school/campus identified in Section 2
above.
I certify that I have not received a refund, tuition recovery, settlement, or other financial restitute to repay the loans that
are the subject of this borrower defense to repayment claim.
I certify that I have accurately reported other efforts I have made to receive loan relief, including by filing suit against the
school, participating in a class action suit, entering into arbitration, applying to a tuition recovery fund, or similar.
I understand that if my application is approved and some or all of my loans are forgiven, I am assigning to the U.S.
Department of Education any legal claim I have against the school for those forgiven loans. By assigning my claims, I am
transferring my interest in any claim that I could make against the school relating to the forgiven loans (including the
ability to file a lawsuit over those forgiven loans and any money ultimately recovered in compensation for those forgiven
loans in court or other legal proceedings) to the U.S. Department of Education. I am not assigning any claims I may have
against the school for any other form of relief –including injunctive relief or damages related to private loans, tuition paid
out-of-pocket, unforgiven loans, or other financial losses.
I understand that the U.S. Department of Education has the authority to verify information reported on this application
with other federal or state agencies or other entities. I authorize the U.S. Department of Education, along with its agents
and contractors, to contact me regarding this request at the phone number above using automated dialing equipment or
artificial or prerecorded voice or text messages.
I understand that any rights and obligations with regard to borrower defense to repayment are subject to the provisions
currently in effect under Title 34 of the Code of Federal Regulations.
Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document
is subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097. I
sign this application under penalty of perjury.
I understand that in the event that I receive a 100 percent discharge of my loan balance for which the defense to
repayment application has been submitted, the school may, if not prohibited by other applicable law, refuse to verify or to
provide an official transcript that verifies my completion of credits or a credential associated with the discharged loan.
I understand that, should the Department receive any documentation from the school, in response to the Department’s
request for records and evidence, the Department will provide me with those documents as well as any evidence
otherwise in the possession of the Department. If my application is based on a loan that I received on or after July 1,
2020, then I further understand that my application and supporting evidence will be sent to my school, and I will have a
time-limited opportunity to review and respond to any evidence that my school submits in response to my application.
I agree to allow the school that is the subject to this defense to repayment application to provide the Department with
items from my student educational record relevant to this defense to repayment application.

Signature Date

Page 24 of 25

We recommend submitting this form online at StudentAid.gov/borrower-defense. If you wish to complete the form
manually, please mail the completed form and documentation to:
U.S. Department of Education, 4255 W HWY 90, Monticello, KY 42633.
If you have questions about your individual submission, please visit StudentAid.gov/help-center/contact or contact the
Borrower Defense Customer Contact Center at 1-855-279-6207 directly.
PRIVACY ACT NOTICE
The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authorities for
collecting the requested information from and about you are §421 et seq., §451 et seq. and §461 et seq. of the Higher
Education Act of 1965, as amended (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., and 20 U.S.C. 1087aa et seq.)
and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA
(20 U.S.C. 1078-2(f) and 20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the William D. Ford Federal
Direct Loan (Direct Loan) Program, the Federal Family Education Loan (FFEL) Program, or the Federal Perkins Loan
(Perkins Loan) 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 Direct Loan Program, FFEL, or Perkins Loan Programs, to
permit the servicing of your loans, and, if it becomes necessary, to locate you and to collect and report on your loans if
your loans becomes delinquent or defaults. 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
loans, to enforce the terms of the loans, 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 to efficiently submit student enrollment statuses, 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 ACT NOTICE
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number. The valid OMB control number for this information collection
is 1845-0163. Public reporting burden for this collection of information is estimated to average .5 hours per response,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. The obligation to respond to this collection is required to
obtain or retain a benefit (20 U.S.C. 1087e(h)). If you have comments or concerns regarding the status of your individual
submission of this application, please contact the Borrower Defense customer Contact Center at 1-855-279-6207
directly. You may also submit and manage your application online at StudentAid.gov/borrower-defense.

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