LOAN DISCHARGE APPLICATION:
TOTAL AND PERMANENT DISABILITY
Federal Family Education Loan Program / Federal Perkins Loan Program / William D. Ford Federal Direct Loan Program
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents will be subject to penalties
which may include fines, imprisonment or both, under the U.S. Criminal Code and 20 U.S.C. 1097.
SECTION I: BORROWER IDENTIFICATION
Please enter or correct the following information.
City, State, Zip
Telephone - Home ( )
Telephone - Other ( )
E-mail address (optional)
SECTION 2: BORROWER DISCHARGE REQUEST
Before signing, carefully read the entire form, including the instructions and other information on the following pages.
Borrower Request, Authorization, Understandings, and Certifications
I request that the U.S. Department of Education (ED) discharge my loan(s) made under the Federal Family Education Loan (FFEL) Program, the Federal Perkins Loan (Perkins Loan)
Program, and/or the William D. Ford Federal Direct Loan (Direct Loan) Program.
I authorize any physician, hospital, or other institution having records about the disability that is the basis for my request for a loan discharge to make information from these
records available to the holder(s) of my loan(s).
I understand that I must submit a separate discharge application to each holder of the loan(s) that I want to have discharged. I further understand that I am not eligible to receive a
final discharge of my loan(s) unless I meet certain requirements during and at the end of a conditional discharge period, as explained in Sections 6 and 7. If 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 discharge of a FFEL Program, Perkins Loan 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