OMBNo.

1845-0120
LOAN REHABILITATION: INCOME ANDEXPENSE Form Approved
INFORMATION Exp. Date 5/31/2020
William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on
RIE
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.
SECTION 1:BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
City State Zip Code
Telephone - Primary
Telephone - Alternate
Email (Optional)

SECTION 2: HOUSEHOLD INCOMEAND REASONABLE AND NECESSARY MONTHLY EXPENSES

You received this form because you asked to rehabilitate your defaulted loans but objected to the payment amount your
loan holder calculated using the 15% formula (see Section 6). After receiving this form, your loan holder will offer an
alternative payment amount. The alternative amount may be less or more than the amount calculated using the 15%
formula. To begin rehabilitating your defaulted loans, you must choose between the two amounts. To rehabilitate, you must
make 9 on-time payments of that amount over a period of 10 consecutive months.
Provide the monthly income and expense information listed below. Include documentation of these sources of income or
expenses if your loan holder asks you to. Include your spouse's income only if your spouse contributes to your household
income. Your loan holder has the authority to determine if the claimed amount of any expense is reasonable and necessary.
Before entering your monthly income and expenses, carefully read the entire form, including Sections 5, 6, and 7.
MONTHLY INCOME MONTHLY EXPENSES
1. Your employment income 10. Food
2. Spouse's employment income 11. Housing
3. Child support received 12. Utilities
4. Social Security benefits 13. Basic communication
5. Worker's compensation 14. Necessary medical/dental
15. Necessary insurance
6. Public assistance
16. Transportation
List types
7. Number of vehicles
Other income
17. Child/dependent care
Describe
18. Required child/spousal support
8. Total monthly income (sum
19. Federal student loan payments
of items 1 through 7)
20. Private student loan payments
9. If your total monthly
21. Other expenses
income is $0, explain
your means of Describe
support 22. Total monthly expenses (sum
of items 10 through 21)

Continue to Sections 3 and 4 on page 2.

Borrower Name Borrower SSN
SECTION 3: FAMILY SIZEAND SPOUSE IDENTIFICATION

Your family size includes you, your spouse, and your children (including unborn children who will be born before the end of
the current calendar year), if the children will receive more than half of their support from you. Your family size includes
other people only if they live with you now, receive more than half of their support from you now, and will continue to receive
this support from you for the year for which you are certifying your family size. Support includes money, gifts, loans,
housing, food, clothes, car, medical and dental care, and payment of college costs.
23. Family size
24. Are you requesting rehabilitation of a Direct Consolidation Loan or a Federal Consolidation Loan that was made jointly to
you and your spouse?
Yes. Enter your spouse's name and SSN:

Spouse's Name Spouse's SSN

X No. Continue to Section 4.
SECTION 4: UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION
I understand that:
1. I have received this form because I requested the opportunity to rehabilitate my defaulted loans and objected to the
reasonable and affordable monthly payment amount calculated using the 15% formula.
2. My loan holder will calculate an alternative reasonable and affordable monthly payment amount that will be based
solely on the information I provide on this form and, if requested, supporting documentation.
3. If I do not accept either the 15% formula payment amount or the payment amount determined by my loan holder
based on information from this form, the loan rehabilitation process will not proceed and I will be required to repay my
defaulted loans in accordance with the terms of the loan and applicable law.
4. If I do not provide any supporting documentation requested by my loan holder by the deadline specified by my
loan holder, my request for loan rehabilitation will not be considered.
5. If I want to rehabilitate a defaulted Direct Consolidation Loan or Federal Consolidation Loan that was made jointly to
me and my spouse and am requesting an alternative payment amount, my spouse and I must each sign below.
6. If I rehabilitate a loan and default on the same loan again in the future, I may not rehabilitate that loan a second time.
7. I must notify my loan holder immediately if my address changes.
8. If my loan is rehabilitated, my loan will be sold or transferred to a new loan holder or loan servicer. After the sale or
transfer, I will be asked to select a repayment plan. If I do not select a repayment plan, my loans will be placed on
the standard repayment plan, which will likely require me to make a much higher monthly payment amount than
the payment I made to rehabilitate my loan.
9. After my loan is rehabilitated, I may be eligible to repay my loans under an income-driven repayment plan that bases
my payment on my income and family size. An income-driven repayment plan is the type of repayment plan most
likely to have a monthly payment similar to the payment I made to rehabilitate my loans.
10. I can learn more about the eligibility requirements and application process for income-driven repayment plans
by visiting StudentAid.gov/IDR or by asking my loan holder.

I certify that (1) the information that I have provided on this form is true and correct and (2) upon request, I will provide
additional documentation to my loan holder to support the information I have provided in this form.
I authorize the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my
request or my loans, including the repayment of my loans, at any number that I provide on this form or any future number
that I provide for my cellular telephone or other wireless device using automated dialing equipment or artificial or
prerecorded voice or text messages.
Borrower's Signature Date

Spouse's Signature Date

Your spouse must sign this form only if you entered your spouse's name and SSN in Section 3.
SECTION 5: INSTRUCTIONS
If you are not completing this form electronically, type or Basic communication: Include the amount spent on
print using dark ink. Enter dates as month-day-year (mm-dd- basic communication expenses, such as basic telephone,
yyyy). Use only numbers. Example: March 14, 2017 = internet, and cable TV.
03-14-2017. Include your name and the account numbers
for your defaulted loans on any documentation that you Medical and dental: Include the amount spent on
are required to submit with this form. If you need help necessary medical and dental expensesand procedures not
completing this form, contact your loan holder. covered by insurance, such as medically necessary
prescription and nonprescription medications, and
Return the completed form to the address shown in medically necessary nutritional supplements. Do not include
Section 8 any costs relating to medical or dental insurance premium
payments.
MONTHLY INCOME INSECTION 2 (ITEMS 1-9)
Your loan holder may request supporting documentation Insurance: Include the amount spent on insurance, such
for any income items. as necessary renter’s, auto, medical, dental, or life insurance.
Include any amounts paid toward insurance premiums.
Employment income documentation may include a pay However, if the income amount you listed under Monthly
stub or a letter from the employer stating the income paid to Income already reflects deductions from your pay for
you by that employer. insurance premiums, do not list the amount of these
deductions as an Insurance expense. Include
Child support, Social Security benefits, worker’s homeowner’s insurance under Item 11 (Housing).
compensation, or public assistance documentation may
include copies of benefits checks or a benefits statement, a Transportation: Include the amount spent on basic
letter from a court, a governmental body, or the transportation expenses such as fuel, car payments, basic
individual paying child support, specifying the amount of vehicle maintenance, public transportation, tolls, and
the benefit. parking. Also list the number of vehicles for which you are
claiming related transportation expenses.
Public assistance: Identify the type of public assistance
received (see definition of “public assistance” in Section 6). Child/dependent care: Include the amount spent on
care for children or other dependents in the household and
Other income: Include any other income not covered in other work-related child/dependent care expenses.
items 1-6 and identify the source of the income.
Legally required child /spousal support: Include the
If you report that your Total Monthly Income is zero, amount spent on legally required child support and spousal
explain your means of support in Item 9. support.
MONTHLY EXPENSES IN SECTION 2 (ITEMS 10-22)
Federal student loan payments: Include the total
For each monthly expense, provide the amount you monthly amount you pay on any federal student loans
usually spend each month. Your loan holder may request except for the defaulted loans you are trying to rehabilitate,
supporting documentation for any of these items. Do not unless you are subject to mandatory withholding such as
include a single expense in more than one category. If you wage garnishment or Treasury offset (e.g., your Social
have no expenses under a category, enter 0 for that Security is being garnished). If you are subject to wage
category. garnishment or Treasury offset include the amount that is
collected from you each month.
Food: Include the amount spent on food, even if
purchased using the Supplemental Nutrition Private student loan payments: Include the total
Assistance Program (SNAP) (food stamps). monthly amount you pay on any private student loans.
Include any type of payment, voluntary or otherwise.
Housing: Include the amount spent on housing and
shelter, such as rent, required security deposits, mortgage Other expenses: Include the amount spent on any other
payments (including principal, interest, taxes, and necessary expenses not covered in items 10 - 20 and explain
homeowner’s insurance), maintenance, and repairs. these expenses. These other expenses will be considered
only if the Department of Education determines that they
Utilities: Include the amount spent on housing-related should be considered. If more space is needed to list other
utility bills, such as gas, electric, fuel oil, water, sewer, trash, expenses, attach a separate piece of paper and include your
and recycling. name and Social Security Number at the top.
SECTION 6: DEFINITIONS

The William D. Ford Federal Direct Loan (Direct Loan)

Program includes Federal Direct Stafford/Ford (Direct Reasonable and affordable payment amount means a
Subsidized) Loans, Federal Direct Unsubsidized Stafford/ monthly payment determined by the loan holder based
Ford (Direct Unsubsidized) Loans, Federal Direct PLUS either on the 15% formula or on information provided in this
(Direct PLUS) Loans, and Federal Direct Consolidation (Direct form and supporting documentation. It cannot be a
Consolidation) Loans. percentage of your total loan balance or based on
information unrelated to your total financial circumstances.
The Federal Family Education Loan (FFEL) Program
includes Federal Stafford Loans (both subsidized and The 15% formula means 15% of the amount by which
unsubsidized), Federal PLUS Loans, Federal Consolidation your Adjusted Gross Income exceeds 150% of the poverty
Loans, and Federal Supplemental Loans for Students (SLS). guideline amount that is applicable to your family size and
state, divided by 12. Your minimum payment may not be
Rehabilitation of your defaulted loan occurs only after less than $5.00.
you have made 9 voluntary, reasonable and affordable
monthly payments within 20 days of the due date during 10 The loan holder of a defaulted Direct Loan Program
consecutive months and, for FFEL loans held by a guaranty loan is the Department. The loan holder of a defaulted FFEL
agency, when the loan has been sold to an eligible lender or Program loan may be a guaranty agency or the Department.
assigned to the U.S. Department of Education (the
Department). When you rehabilitate your loans, you will Public assistance means payments you receive under a
regain all the benefits of the Direct Loan Program or FFEL federal or state program. These assistance programs include,
Program, including eligibility for deferments or forbearances but are not limited to, Temporary Assistance for Needy
and for a repayment plan with a monthly payment amount Families (TANF), Supplemental Security Income (SSI), Food
based on your income. You will also regain eligibility to Stamps/Supplemental Nutritional Assistance Program
receive additional federal student aid, including additional (SNAP), or state general public assistance.
federal student loans. After a defaulted loan is rehabilitated,
your loan holder will instruct any consumer reporting
agency (credit bureau) to which the default was reported to
remove the default from your credit history.

SECTION 7: LOAN REHABILITATION AGREEMENT

To rehabilitate your loan, you must accept either the To accept the loan rehabilitation agreement, you must
monthly rehabilitation payment amount determined using sign the agreement and return it to your loan holder.
the 15% formula, or the payment amount determined based During the loan rehabilitation period, the loan holder
on the monthly income, monthly expenses, and family size will limit contact with you on the loan being rehabilitated to
information that you provide on this form and on any collection activities that are required by law or regulation,
requested supporting documentation. and to communication that supports the rehabilitation.
Your loan holder will provide you with a written loan If you do not accept either monthly payment amount,
rehabilitation agreement confirming your monthly your rehabilitation request will not be considered any
rehabilitation paymentamount. further.

SECTION 8: WHERE TO SEND THE COMPLETED FINANCIAL DISCLOSURE FORM

Return the completed form and any documentation to: If you need help completing this form, call:
Action Financial Services, LLC If you have any questions, please contact your
Dba AFCS, LLC in Connecticut, Delaware, Iowa Action Financial Services Representative at
Michigan, Texas & Washington 888-253-4239.
P.O. Box 3250, Central Point, OR 97502
Fax #: 1-844-965-9229
[email protected]
SECTION 9: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. To assist program administrators with tracking
552a) requires that the following notice be provided to you: refunds and cancellations, disclosures may be made to
The authorities for collecting the requested guaranty agencies, to financial and educational institutions,
information from and about you are §421 et seq. and §451 or to federal or state agencies. To provide a standardized
et seq. of the Higher Education Act of 1965, as amended (20 method for educational institutions to efficiently submit
U.S.C. 1071 et seq. and 20 U.S.C. 1087a et seq.) and the student enrollment statuses, disclosures may be made to
authorities for collecting and using your Social Security guaranty agencies or to financial and educational
Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 institutions. To counsel you in repayment efforts, disclosures
U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b). may be made to guaranty agencies, to financial and
Participating in the William D. Ford Federal Direct Loan educational institutions, or to federal, state, or local
(Direct Loan) Program or the Federal Family Education Loan agencies.
(FFEL) Program and giving us your SSN are voluntary, but In the event of litigation, we may send records to the
you must provide the requested information, including your Department of Justice, a court, adjudicative body, counsel,
SSN, to participate. party, or witness if the disclosure is relevant and necessary
The principal purposes for collecting the to the litigation. If this information, either alone or with
information on this form, including your SSN, are to verify other information, indicates a potential violation of law, we
your identity, to determine your eligibility to receive a loan may send it to the appropriate authority for action. We
or a benefit on a loan (such as a deferment, forbearance, may send information to members of Congress if you ask
discharge, or forgiveness) under the Direct Loan and/or them to help you with federal student aid questions. In
FFEL Programs, to permit the servicing of your loans,and, if circumstances involving employment complaints,
it becomes necessary, to locate you and to collect and grievances, or disciplinary actions, we may disclose relevant
report on your loans if your loans become delinquent or records to adjudicate or investigate the issues. If provided
default.We also use your SSN as an account identifier and for by a collective bargaining agreement, we may disclose
to permit you to access your account information records to a labor organization recognized under 5 U.S.C.
electronically. Chapter 71. Disclosures may be made to our contractors for
the purpose of performing any programmatic function that
The information in your file may be disclosed, on a requires disclosure of records. Before making any such
case-by-case basis or under a computer matching program, disclosure, we will require the contractor to maintain Privacy
to third parties as authorized under routine uses in the Act safeguards. Disclosures may also be made to qualified
appropriate systems of records notices. The routine uses researchers under Privacy Act safeguards.
of this information include, but are not limited to, its Paperwork Reduction Notice. According to the
disclosure to federal, state, or local agencies, to private Paperwork Reduction Act of 1995, no persons are
parties such as relatives, present and former employers, required to respond to a collection of information unless
business and personal associates, to consumer reporting such collection displays a valid OMB control number.
agencies, to financial and educational institutions, and to
The valid OMB control number for this information
guaranty agencies in order to verify your identity, to collection is 1845-0120.Public reporting burden for this
determine your eligibility to receive a loan or a benefit on a collection of information is estimated to average 60
loan, to permit the servicing or collection of your loans, to minutes per response, including time for reviewing
enforce the terms of the loans, to investigate possible fraud instructions,
and to verify compliance with federal student financial aid searching existing data sources, gathering and maintaining
program regulations, or to locate you if you become
the data needed, and completing and reviewing the
delinquent in your loan payments or if you default. To
collection of information. The obligation to respond to this
provide default rate calculations, disclosures may be made
collection is required to obtain a benefit in accordance with
to guaranty agencies, to financial and educational
34 CFR682.405 or 685.211. If you have questions regarding
institutions, or to state agencies. To provide financial aid
the status of your individual submission of this form, contact
history information, disclosures may be made to
your loan holder (see Section 8).
educational institutions.
 2.0 – Appendix B – FIS Borrower Supplement Documentation
Required for Loan Rehabilitation: Income and Expense Information

In addition to the LOAN REHABILITATION: INCOME AND EXPENSE INFORMATION form, please provide the following
supporting documentation.
Section 1: Income (Include income documents for your spouse if you are married and living together)
Field Please Include the Following Documentation
1 Your Employment Income Signed copy of your most recent 1040 (both pages), or Federal l tax return transcript
for either of the two previous tax years.

Most recent W2 or 2 pay stubs (neither document can be more than 90 days old)
2 Spouse’s Employment Income
If you or your spouse is self-employed, provide the most recent signed 1040 or 1040-
ES worksheet.
3 Child Support Received A copy of your divorce decree or support order. If these are not available, or you are
not receiving the full amount ordered, provide a written statement explaining how
much you are receiving.
4 Social Security Benefits A benefits statement from the Social Security Administration
5 Worker’s Compensation A pay stub and/or benefit letter (no older than 90 days)
6 Public Assistance A copy of your award letter
7 Other Income Any documentation showing the source and amount
8 Total monthly income Add the amounts placed in each field for income (1-7) and place that amount here.
9. If your monthly income is $0, If the above field (8) is $0, explain how or by whom you are being supported and the
explain your means of support source(s) of income for the person supporting you.
Section 2: Expenses
10 Food None required
11 Housing If you live in the U.S. (including Puerto Rico): none required

12 Utilities If you live outside the U.S., copies of:

1. Mortgage statement or rental agreement, home/renters insurance bills, and
13 Basic Communication 2. Utility bills, and
3. Basic communication bills (internet, phone, basic cable)
14 Necessary medical/dental None required, if you spend less than $60 a mos per person in your family.
If you spend more than that, provide proof of what you actually spend out of pocket
on co-payments for prescription drugs, doctor visits, and other medical needs:
canceled checks and/or receipts, statements, etc.
Providing only a bill showing amount owed is not acceptable.
15 Necessary Insurance Health insurance: copies of your premium statement or pay stub
Life insurance is only allowed if required by court order; provide copies of the premium
statement and court order.
Do not include auto insurance here (include that in transportation expenses)
Do not include homeowners or rental insurance here (include that in housing)
16 Transportation/Number of If you live in the U.S. (including Puerto Rico): none required
vehicles
If you live outside the U.S.: documents showing car payments, auto insurance, gas/oil,
maintenance, and car registration.

Page 6
17 Child/dependent care Two most recent receipts/canceled checks from your day care provider (dated within
past 90 days)
Also include mandatory work-related expenses or deductions, or court-ordered
dependent expenses:
- Union dues
- Retirement contributions (do not include voluntary Thrift, 401k or IRA allotments)
- Garnishments for taxes (borrower must provide proof of garnishment source)
- Only include private school tuition if it is court ordered (include a copy of the court
order).
18 Required child/spousal Court order (unless it is shown on your pay stub)
support
19 Federal Student Loan Current billing statement (less than 90 days old) for other Federal student loans you
Payments owe (do not include the loans for which you are completing this form)
Section 2: Expenses (Continued)
Field Please Include the Following Documentation
20 Private Student Loan Current billing statement (less than 90 days old)
Payments
21 Other Expenses None required
22 Total monthly expenses Add the amounts placed in each field for expenses (10-21) and place that amount
here.
Section 3: Family Size, Adjusted Gross Income, and Spousal Information
23 Family Size None Required
24 Spouse’s Name and SSN None Required

Page 7
 If you have income listed on line 7 please
complete the following for “Other” income:

To whom it may concern:

I, , certify that I earn $
per month in “Other” income. The source of the “Other”
income is (provide statement on how the “Other” income is earned)

Borrower’s SSN:
Borrower’s Signature:

Date:

This is an attempt to collect a debt and any information obtained will be used for that purpose.

Page 8
 dba AFCS, LLC in Connecticut,
Delaware, Iowa, Michigan, Texas & Washington
P.O. Box 3250, Central Point, OR 97502

Third Party Authorization Form

Name: Date:

Account Number or SSN

I hereby authorize _____________________________________________ as someone that Action Financial Services

and/or a subcontractor office, may speak with regarding my student loan account. This authorization will remain in
effect, unless revoked by me verbally or in writing, or revoked by the authorized third party verbally or in writing, for as
long as my account remains with Action Financial Services or one of their subcontractors.

I understand that important information such as payment options and repayment program requirements may be
discussed with the authorized third party and that it is my responsibility to communicate with the 3 rd party to make sure
I receive the information in a timely fashion. I understand that failure to do so may cause issues with my payments,
return of required documents or completion of any voluntary payment program I participate in.

Borrower Name (Please print):

Borrower Signature:

Authorized Third Party Name (Please print):

Authorized Third Party Phone Number:

This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be
used for that purpose.

Rev. 1 8/16/2018

Page 9
 Rehabilitation Program Check List
Your Personal “All in One” Guide to Success

To complete the Rehabilitation Program, the following steps must be achieved with…

Accuracy……… using a blue or black pen

Timeliness……. meeting deadlines with your Account Specialist
Passion………. to create a new opportunity

Please print this document for reference as it outlines which forms, (from this site), you will need
to Complete the program. You will also use it for planning sessions with your Account Specialist.

***Call your Account Specialist with any questions when completing your checklist for the Rehabilitation Program***

Tasks Document Name on Website Completion Date

Step 1: Financial Statement FIS Statement

(Complete this step with your Account Specialist) (Loan Rehabilitation: Income and Expense Information)

Step 2: Check Stubs (2 most recent)

(Use Gross Income and make sure copies are clear…include Spouses if married)

Step 3: Identify Adjusted Gross Income (AGI)

(Tax Return 1040-physically sign 1040-only include if not sending Check Stubs)

Step 4: Other Income Possible Document Needed

(List on lines 3-7 and send proof of each…such as Award Letter, etc…) (Other Income Certification)

Step 5: If Total Monthly Income equals $0

(List on line 9 and write name of who supports you, relation to you and where they work or how support themselves)

Step 6: Other Financial Obligations

(List on lines 10-21 and send proof for anything listed on lines 14,15 and 17-21)

Step 7: Send Completed Documents

(Send via Fax to 1-844-965-9229 or Secure Email)

Step 8: Secure Payment Arrangements

(Complete this step with your Account Specialist)

Step 9: Rehabilitation Agreement Letter

(Send via Fax to 1-844-965-9229 or Secure Email back then call your Account Specialist)

***(Phone Number 888-253-4239, Fax# 1-844-965-9229, Secure Email – [email protected])***

Rev. 3 9/20/2018

Page 10