U.S. Repatriation Loan Waiver and Deferral Request Form

This Repatriation Loan Waiver and Deferral Request Form is to be completed by individuals who have received temporary assistance through the U.S. Department of Health and Human Services (HHS) Repatriation Program, and want to request a waiver or deferral of their repatriation loan. In addition, this form can be completed by:

• Adults applying on behalf of themselves and dependents;
• Adult representative of a minor child (parent, guardian, or legal representative);
• Adult representative of a mentally or physically impair adult.

The U.S. Repatriation Program may perform an investigation and at its discretion to determine whether to waive the whole or any portion of a repatriation loan. In addition, it may grant a deferral instead of a waiver if it is determined that the prospects of future collection are promising enough to justify periodic review of the debt. Eligibility determinations are made by the Administration for Children and Families (ACF) in accordance to 45 CFR 211.13 and 212.7. This form must be submitted to the U.S. Repatriation Program at the address listed at the top of this form. The application must contain necessary supporting documentation. For more information or to obtain an electronic copy of this form, please visit the U.S. Repatriation Program website at: /programs/orr/programs/repatriation. DO NOT complete this form if you are looking for a payment plan.

For inquiries related to your loan collection and payment plan, please contact the HHS-Program Support Center at: Accounting Services — Debt Collection Center, 7700 Wisconsin Avenue, Suite 8- 8110D, Mail Stop 1023B, Bethesda, Maryland 20857 (Zip Code 20814 for UPS/FEDEX Mail). Email: PSCDebtServicing@psc.hhs.gov Telephone: 301-492-4664