WARNING: Any person who knowingly makes a false statement or misrepresentation on this form will be subject to penalties which may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.
OMB No. 1845-0053 Form Approved Exp. Date 11/30/2010
Before You Begin
Read the instructions forcompleting this Federal Direct Consolidation Loan Application and Promissory Note. Print using blue or black ink or type. You must sign and date this form. If you cross out anything and write in new information, put your initials beside the change. NOTE: PAGES 1, 2, and 3 OF THIS FORM MUST BE SUBMITTED IN ORDER TO PROCESS YOUR LOAN REQUEST.
Section A: Borrower Information 1. Last Name First Name MiddleInitial 2. Social Security Number
3. Permanent Street Address (if P.O. box or general delivery, see instructions) ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________ _____________ _______________________ City State Zip Code 6. Former Name(s) 9.Employer’s Name 11. Work Area Code/Telephone Number 7. Date of Birth (mm-dd-yyyy) 10. Employer’s Address City
4. Area Code/Telephone Number
5. E-Mail Address (Optional) 8. Driver’s License State and Number State -Number
Section B: Reference Information 12. References: List two persons with different addresses who have known you for at least threeyears. Do not list individuals who live with you (for example, your spouse) or who live outside the United States. Name 1. 2.
Permanent Address City, State, Zip Code E-Mail Address (optional) Area Code/Telephone Number Relationship to Borrower Section C1: Education Loan Indebtedness – Loans You Want to Consolidate (continued on page 2) Read the instructions before completing this section. Listeach federal education loan that you want to consolidate, including any William D. Ford Federal Direct Loan (Direct Loan) Program loans that you want to include in your Direct Consolidation Loan. If you need more space to list additional loans, use the Additional Loan Listing Sheet included with this package. List each loan separately. Please print. ONLY LIST LOANS THAT YOU WANT TO CONSOLIDATE INTHIS SECTION. 13. Loan Type
14. Loan Holder’s/Servicer’s Name, Address, and Area Code/Telephone Number
15. Loan Account Number
16. Estimated Payoff Amount
Submit pages 1, 2, and 3
Page 1 of 9
Borrower’s Name (please print)
Social Security Number
16. Estimated Payoff Amount
Section C1: Education LoanIndebtedness – Loans You Want to Consolidate (continued from page 1) 13. Loan Type 14. Loan Holder’s/Servicer’s Name, Address, and Area Code/Telephone Number 15. Loan Account Number
(See Instructions) (See Instructions)
W W W W W W
17. Grace Period End Date. If any of the loans you want to consolidate are in a grace period, you can delay the processing of your Direct Consolidation Loan until theend of your grace period by entering your expected grace period end date in the space provided. If you leave this item blank, your Direct Consolidation Loan will be processed and any loans listed in Section C1 that are in a grace period will enter repayment immediately upon consolidation. Expected Grace Period End Date (month/year): _________________________
Section C2: Education LoanIndebtedness – Loans You Do Not Want to Consolidate Read the instructions before completing this section. List all education loans that you are not consolidating, but want to have considered when calculating your maximum repayment period. Include any Direct Loan Program loans that you do not want to consolidate. If you need more space to list additional loans, use the Additional Loan Listing Sheet...