By completing this form and acknowledging below, I am expressing my desire to participate in the Fresh Start program.

Social Security Number:*

Confirm Social Security Number:*

Name:*

Date of Birth:*

Street Address 1:*

Street Address 2:

City:*

State:*

Zip Code:*

Primary Phone:* Is this a mobile phone?* Yes No

Email:*

Data Related to Income Driven Repayment
If you provide information in this section, all fields must be completed. If “Married Filing Separately” is indicated, your spouse's AGI information will be required.
Your household size: Include yourself, your spouse (if married), any children who receive more than half of their support from you, any unborn children who will be born before the end of this current calendar year, and any other relatives living with you and who receive more than half of their support from you. Note: Types of support include money (including loans), housing, food, clothing, transportation, medical and dental care, costs of college attendance.
Your filing status from your most recent federal tax return.
Number of Dependents claimed on your tax return.
Your adjusted gross income from your most recent federal tax return. (You can still apply if you don’t file taxes because your income is too low.)
Your spouse's adjusted gross income.

Active Bankruptcy Data
This only applies if you have an active bankruptcy.
Case Number
Chapter
Filed Date
Filed Location

I authorize the Department of Education and its contractors to contact me regarding my loans, including repayment of my loans, at any cellular telephone number I have provided previously, or that I provide now or in the future, using automated dialing equipment or artificial or prerecorded voice or text messages.* Yes No

By completing this form and acknowledging below, I am expressing my desire to participate in the Fresh Start program.

You will only be allowed to submit this form once as duplicate entries will not be allowed.