Private Education Loan Applicant Self-Certification (Omb No. 1845-0101) - 2010

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Private Education Loan

OMB No. 1845-0101

Form Approved

Exp. Date 02-28-2013

Applicant Self-Certification

________________________________________________________________________________________________

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. The school is required on request to provide

this form or the required information only for students admitted or enrolled at the school. 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 person.

Instructions: Before signing, carefully read the entire form, including the definitions and other information on the following page. Submit the signed form

to your lender.

SECTION 1: NOTICES TO APPLICANT

Free or lower-cost Title IV federal, state, or school student financial aid may be available in place of, or in addition to, a private



education loan. To apply for Title IV federal grants, loans and work-study, submit a Free Application for Federal Student Aid

(FAFSA) available at , or by calling 1-800-4-FED-AID, or from the school’s financial aid office.

A private education loan may reduce eligibility for free or lower-cost federal, state, or school student financial aid.



You are strongly encouraged to pursue the availability of free or lower-cost financial aid with the school’s financial aid office.



The financial information required to complete this form can be obtained from the school’s financial aid office. If the lender has



provided this information, you should contact your school’s financial aid office to verify this information and to discuss your

financing options.

SECTION 2: COST OF ATTENDANCE AND ESTIMATED FINANCIAL ASSISTANCE

If information is not already entered below, obtain the needed information from the school’s financial aid office and enter it on the appropriate line. Sign

and date where indicated.

A. Student’s cost of attendance for the period of enrollment covered by the loan

$____________________

B. Estimated financial assistance for the period of enrollment covered by the loan

$____________________

C. Difference between amounts A and B

$____________________

WARNING: If you borrow more than the amount on line C, you risk reducing your eligibility for

free or lower-cost federal, state, or school financial aid.

SECTION 3: APPLICANT INFORMATION

Enter or correct the information below.

University of North Dakota, 264 Centennial Drive Stop 8371, Grand Forks, ND 58202-8371

Full Name and Address of School ________________________________________________________________________________________________________

Applicant Name (last, first, MI) ___________________________________________________

Date of Birth (mm/dd/yyyy) _____/_____/__________

Permanent Street Address __________________________________________________________________

City, State, Zip Code __________________________________________________________________ ____________________

Area Code / Telephone Number Home (

) ____________________________

Other (

) ____________________________

E-mail Address________________________________________________________________________________________

Period of Enrollment Covered by the Loan (mm/dd/yyyy)

From _____ / _____ / _______ to _____ / _____ / _______

If the student is not the applicant, provide the student’s name and date of birth.

Student Name (last, first, MI) ____________________________________________________

Student Date of Birth (mm/dd/yyyy) _____/_____/__________

SECTION 4: APPLICANT SIGNATURE

I certify that I have read and understood the notices in Section 1 and, that to the best of my knowledge, the information provided on this form is true and correct.

Signature of Applicant ____________________________________________________________________ Date (mm/dd/yyyy) _______________________

2/12/2010