Private Education Loan Applicant Self-Certification

Private Education Loan Applicant Self-Certification
For lender use only
Private Education Loan
Applicant Self-Certification
Form Approved
Exp. Date XX-XX-XXXX
Important: Pursuant to section 155 of the Higher Education Act of 1965, as amended, (HEA) and to satisfy the requirements of section 128(e)(3) of
the Truth in Lending Act, a lender must obtain a self-certification signed by the applicant before disbursing a private education loan. Throughout this
Applicant Self-Certification, “you” and “your” refer to the applicant who is applying for the loan. The applicant and the student may be the same
Instructions: Before signing, carefully read the entire form, including the definitions and other information on the following page. Return
the signed form to your lender.
Enter or correct the information below.
Complete the item below if the student is a different person from the applicant.
Applicant Name (last, first, MI) _______________________________________________
Student Name (last, first, MI) ____________________________________________
Permanent Address ________________________________________________________
City, State, Zip Code _______________________________________________________
Area Code / Telephone Number
Home (
) _________ Other (
) ___________
E-mail Address ____________________________________________________________
Name of School ________________________________________________
Period of Enrollment Covered by the Loan: From _____ / _____/ _______ to _____ / _____ / _______
You (or the student, when the applicant is not the student) may qualify for federal, state, or
school student financial assistance, in place of, or in addition to, a private education loan.
A private education loan may reduce eligibility for free or low-cost federal, state, or school
student financial assistance.
You should discuss the availability of federal, state, and school student financial assistance
with a financial aid administrator at the school.
The information you are required to provide on this self-certification must be secured from the
school financial aid office.
If information is not already entered below, obtain the needed information from the school financial aid office and enter it on the appropriate line. Sign and date where
Student’s cost of attendance for the period of enrollment covered by the loan
Estimated financial assistance
Difference between amounts A and B (A – B = C)
A loan amount greater than this amount can reduce eligibility for other student financial aid as shown in item B.
I certify, to the best of my knowledge, that the information I have provided is true and correct.
Signature of Applicant ____________________________________________________________________ Date _______________________
Cost of attendance is an estimation of tuition and fees, room and board, transportation and other costs for the period of enrollment covered by the
loan, as determined by the school. A student’s cost of attendance may be obtained by the student from the school financial aid office.
Estimated financial assistance is all federal, state, institutional (school), private and other sources of assistance used in determining eligibility for
most Title IV student aid, including amounts of financial assistance used to replace the expected family contribution. The student’s estimated
financial assistance is determined by the school, and may be obtained by the student from the school’s financial aid office.
Expected family contribution is the amount a student and his or her spouse and family are expected to contribute toward the student's cost of
attendance, as determined under Title IV, Part F of the Higher Education Act of 1965, as amended.
A lender is a private education lender as defined in Section 140 of the Truth in Lending Act; and any other person engaged in the business of
securing, making, or extending education loans on behalf of the lender.
Period of enrollment is the academic year, academic term (such as semester, trimester, or quarter) or the number of weeks of instructional time for
which the applicant is requesting student financial assistance.
A private education loan is a loan provided by a private educational lender that is not a Title IV loan and that is issued expressly for postsecondary
education expenses to a borrower, regardless of whether the loan is provided through the educational institution that the student attends or directly
to the borrower from the private educational lender. A private education loan does not include (1) An extension of credit under an open end
consumer credit plan, a reverse mortgage transaction, a residential mortgage transaction, or any other loan that is secured by real property or a
dwelling; or (2) An extension of credit in which the educational institution is the lender if the term of the extension of credit is 90 days or less or
an interest rate will not be applied to the credit balance and the term of the extension of credit is one year or less, even if the credit is payable in
more than four installments.
Title IV student aid includes the Federal Pell Grant Program; the Academic Competitiveness Grant (ACG) Program; the Federal Supplemental
Educational Opportunity Grant (FSEOG) Program ; the Leveraging Educational Assistance Partnership (LEAP) Program; the Federal Stafford Loan
Program; the Federal PLUS Program; the Federal Consolidation Loan Program; the Federal Work-Study (FWS) Program; the William D. Ford
Federal Direct Loan (Direct Loan) Program; the Federal Perkins Loan Program; the National Science and Mathematics Access to Retain Talent
Grant (National SMART Grant) Program; and the Teacher Education Assistance for College and Higher Education (TEACH) Grant program.
SECTION 5: Paperwork Reduction Notice
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-XXXA. The time required to complete this information collection is estimated to average 0.25
hours (15 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
If 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, contact your lender.
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