Public Service Loan Forgiveness (Pslf): Employment Certification Form printable pdf download

PUBLIC SERVICE LOAN FORGIVENESS (PSLF):

OMB No. 1845-0110

Form Approved

EMPLOYMENT CERTIFICATION FORM

Exp. Date 12/31/2017

William D. Ford Federal Direct Loan (Direct Loan) Program

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: BORROWER IDENTIFICATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Date of Birth

___ ___ - ___ ___ - ___ ___ ___ ___

Name

___________________________________________

Former Name (if any)

___________________________________________

Address

___________________________________________

City, State, Zip

________________________ , _______ __________

Telephone – Primary

( ___________ ) ___________ - _________________

Telephone – Alternate

( ___________ ) ___________ - _________________

E-mail (optional)

___________________________________________

SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS

Before signing, carefully read the entire form. For more information about PSLF, visit StudentAid.gov/publicservice.

I authorize:

1. My employer or other entity having records about the employment that is the basis of my request to make

information from those records available to the U. S. Department of Education (the Department) or its agents or

contractors.

2. The Department (and its agents or contractors) to contact me regarding my request or my loan(s), including

repayment of my loan(s), at the telephone number that I provide on this form or any future number that I provide

for my cellular telephone or other wireless device using automated telephone dialing equipment or artificial or

prerecorded voice or text messages.

I understand that:

1. To qualify for PSLF, I must make 120 qualifying payments on my Direct Loan(s) while employed full-time by a

qualifying employer or employers. Neither the 120 qualifying payments nor employment have to be consecutive.

2. To qualify for PSLF, I must be employed full-time by a qualifying employer or employers when I apply for PSLF and

when my loan is forgiven.

3. If I qualify for forgiveness, only the remaining balance on my Direct Loan(s) will be forgiven.

4. By submitting this form, my student loan(s) held by the Department will be transferred to FedLoan Servicing.

5. The Department may request supplemental documentation substantiating my employment.

6. The Department will notify me in writing or electronically of the number of qualifying payments I have made while

employed full-time by a qualifying employer or employers and the remaining number of qualifying payments I

must make before I am eligible to apply for PSLF.

7. The Department will notify me in writing or electronically if the form that I submit is incomplete, or if it

determines that my employment or payments do not qualify for PSLF. The Department will explain the reason for

the determination and the steps I need to take to correct the form or make qualifying payments.

8. The Department will retain this certification form until I submit my application for forgiveness.

I certify that all of the information I have provided on this form and in any accompanying document is true, complete,

and correct to the best of my knowledge and belief.

Check this box if you cannot obtain certification from your employer because the organization is closed or because

the organization has refused to certify your employment. The Department will follow up to assist you in getting

documentation of your employment. Complete Section 3, but do not complete Section 4.

Borrower Signature _______________________________________________ Date ___ ___ - ___ ___ - ___ ___ ___ __

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Public Service Loan Forgiveness (Pslf): Employment Certification Form

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