APPLICANT REPRESENTATIVE DESIGNATION: TOTAL OMB No.

1845-0065
OMB Approved
AND PERMANENT DISABILITY Exp. Date 8/31/2024
William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan)
Program / TEACH Grant Program
TPD-REP
WARNING: 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.
SECTION 1: DISCHARGE APPLICANT INFORMATION
Please enter or correct the following information.
Do not enter information about the representative in this section.
Check this box if any of your information has changed.
SSN
Name
Address
City State Zip Code
Telephone - Primary
Telephone - Alternate
Email
SECTION 2: DESIGNATION, CHANGE, OR REVOCATION OF APPLICANT REPRESENTATIVE
This form is required to designate an individual or organization to represent you in matters related to your total and
permanent disability discharge request, even if that individual or organization already has authority to act on your behalf, for
example, through a power of attorney. Before completing this form, carefully read the entire form, particularly Section 3.
Type or print using dark ink. Return this form to the address shown in Section 4.
1. Why are you completing this form?
I am designating an individual or organization to represent me in all matters relating to my total and permanent
disability request - Continue to Item 2.
I am changing the individual or organization that represents me in all matters relating to my total and permanent
disability request - Continue to Item 2.
I am revoking my previous designation of an individual or organization that represents me in all matters related to
my total and permanent disability request. I no longer wish to have a representative. Skip to Section 3.
2. Please provide contact information for the representative that you are designating. If you are designating an
organization, you do not need to provide a name of an individual at the organization that will be your representative.
However, you must provide a Taxpayer ID Number.

Individual Name
Organization Name
Organization Taxpayer ID Number
Address
City State Zip Code
Telephone - Primary
Telephone - Alternate
Email

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Applicant Name Applicant SSN
SECTION 3: APPLICANT'S REQUEST, UNDERSTANDINGS, AUTHORIZATION, AND CERTIFICATION

I request to designate, change, or revoke an individual or organization to represent me in all matters related to my total and
permanent disability discharge request. If I have not already submitted an application for total and permanent disability
discharge, I intend to do so.
I understand that:
1. The individual or organization that I designate in Section 2 will have the ability to receive information about my total and
permanent disability discharge request for my federal student loans or TEACH Grants that is otherwise protected by the
Privacy Act of 1974 and will have the ability to act on my behalf as it relates to my total and permanent disability
discharge request, including the authority to apply for a discharge, provide notifications or information to the U.S.
Department of Education (the Department), and receive notifications and correspondence from the Department.
2. To verify my representative's identity when making a request for disclosure or providing information by telephone, the
representative may be required to provide my name, Social Security Number, and date of birth.

3. When requesting the disclosure of information, the representative named in Section 2 must submit information to verify
his or her identity or the organization for which he or she works.

4. If I am requesting to change or revoke the individual or organization that represents me, the individual or organization
that I previously designated will no longer be my representative as of the date that the Department receives my request.

5. If I am requesting to revoke the individual or organization that represents me, I may do so in any oral or written
communication to the Department.
6. My representative may also revoke my designation in any oral or written communication to the Department; and

7. My designation, change, or revocation will be effective on the date that the Department receives and (if written)
processes my communication.

I authorize the Department and its agents to release to, and discuss with, the individual or organization named in Section 2,
any records held by the Department regarding my federal student loan or TEACH Grant service obligation(s) and to send
correspondence related to my discharge request to that individual or organization. I also authorize the individual or
organization named in Section 2 to assist me in satisfying the obligation through a total and permanent disability discharge.
I certify that all of the information I have provided on this form and in any accompanying documentation is true, complete,
and correct to the best of my knowledge and belief.

Applicant's Signature Date

Representative's Signature Date

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SECTION 4: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to: If you need help completing this form, contact us:
U.S. Department of Education - TPD Servicing Phone: 1-888-303-7818 (TTY: dial 711, then phone no.)
P.O. Box 87130 Fax: 303-696-5250
Lincoln, NE 68501-7130 Email: [email protected]
Fax to: 303-696-5250 Website: www.disabilitydischarge.com
Email to: [email protected]
SECTION 5: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. To assist program administrators with tracking refunds
552a) requires that the following notice be provided to you: and cancellations, disclosures may be made to guaranty
The authorities for collecting the requested information agencies, to financial and educational institutions, or to
from and about you are §421 et seq., §451 et seq., §461, or federal or state agencies. To provide a standardized method
§420L of the Higher Education Act of 1965, as amended (20 for educational institutions to efficiently submit student
U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa enrollment statuses, disclosures may be made to guaranty
et seq., or 20 U.S.C. 1070g et seq.) and the authorities for agencies or to financial and educational institutions. To
collecting and using your Social Security Number (SSN) are counsel you in repayment efforts, disclosures may be made
§§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and to guaranty agencies, to financial and educational
1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Direct institutions, or to federal, state, or local agencies.
Loan,FFEL, Perkins Loan, or TEACH Grant program and In the event of litigation, we may send records to the
giving us your SSN are voluntary, but you must provide the Department of Justice, a court, adjudicative body, counsel,
requested information, including your SSN, to participate. party, or witness if the disclosure is relevant and necessary
The principal purposes for collecting the information on to the litigation. If this information, either alone or with
this form, including your SSN, are to verify your identity, to other information, indicates a potential violation of law, we
determine your eligibility to receive a loan or a benefit on a may send it to the appropriate authority for action. We may
loan (such as a deferment, forbearance, discharge, or send information to members of Congress if you ask them
forgiveness) under the Direct Loan, FFEL, Federal Perkins to help you with federal student aid questions. In
Loan or TEACH Grant Programs, to permit the servicing of circumstances involving employment complaints,
your loans, and, if it becomes necessary, to locate you and grievances, or disciplinary actions, we may disclose relevant
to collect and report on your loans if your loans become records to adjudicate or investigate the issues. If provided
delinquent or default. We also use your SSN as an account for by a collective bargaining agreement, we may disclose
identifier and to permit you to access your account records to a labor organization recognized under 5 U.S.C.
information 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 case- requires disclosure of records. Before making any such
by-case basis or under a computer matching program, to disclosure, we will require the contractor to maintain Privacy
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 of researchers under Privacy Act safeguards.
this information include, but are not limited to, its disclosure Paperwork Reduction Notice. According to the
to federal, state, or local agencies, to private parties such as Paperwork Reduction Act of 1995, no persons are required
relatives, present and former employers, business and to respond to a collection of information unless such
personal associates, to consumer reporting agencies, to collection displays a valid OMB control number. The valid
financial and educational institutions, and to guaranty OMB control number for this information collection is
agencies in order to verify your identity, to determine your 1845-0065. Public reporting burden for this collection of
eligibility to receive a loan or a benefit on a loan, to permit information is estimated to average 30 minutes per
the servicing or collection of your loans, to enforce the response, including time for reviewing instructions,
terms of the loans, to investigate possible fraud and to verify searching existing data sources, gathering and maintaining
compliance with federal student financial aid program the data needed, and completing and reviewing the
regulations, or to locate you if you become delinquent in collection of information. The obligation to respond to this
your loan payments or if you default. To provide default rate collection is required to obtain a benefit in accordance with
calculations, disclosures may be made to guaranty agencies, 34 CFR 674.61(b) or (c), 34 CFR 682.402(c)(2) or (c)(9), 34 CFR
to financial and educational institutions, or to state 685.213(b) or (c), and 34 CFR 686.42(b). If you have
agencies. To provide financial aid history information, comments or concerns regarding the status of your
disclosures may be made to educational institutions. individual submission of this form, please contact the U.S.
Department of Education directly (see Section 6).
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