Public Service Loan Forgiveness (Pslf): Employment Certification Form (Page 2 of 6) in pdf

Borrower Name: ___________________________________

Borrower SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 3: EMPLOYMENT INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)

10. Is your employer a tax-exempt organization under

1. Employer Name: ______________________________

section 501(c)(3) of the Internal Revenue Code?

____________________________________________

Yes – Skip to Section 4

2. Federal Employer Identification Number (EIN):

No – Continue to Item 11.

___ ___ - ___ ___ ___ ___ ___ ___ ___

11. Is your employer a not-for-profit organization?

Your employer’s EIN may be found on your Wage and

Tax Statement (W-2).

Yes – Continue to Item 12.

3. Employer Address:

No – Your employer does not qualify.

____________________________________________

12. Is your employer a partisan political organization?

____________________________________________

Yes – Your employer does not qualify.

4. Employer Website (if any)

No – Continue to Item 13.

____________________________________________

13. Is your employer a labor union?

5. Employment Begin Date:

Yes – Your employer does not qualify.

___ ___ - ___ ___ - ___ ___ ___ ___

No – Continue to Item 14.

6. Employment End Date:

14. Does your employer provide any of the below

___ ___ - ___ ___ - ___ ___ ___ ___ OR

services?

Still employed.

Yes – Select all the services your employer

provides and then continue to Section 4.

7. Employment Status:

Full-Time

Part-Time

Emergency management

8. Hours Per Week (Average): __________________

Military service (see Section 6)

Include vacation, leave time, or any leave taken under

Public safety

the Family Medical Leave Act of 1993. If your

Law enforcement (see Section 6)

employer is a 501(c)(3) or a not-for-profit

Public interest legal services (see Section 6)

organization, do not include any hours you spent on

Early childhood education (see definition of

religious instruction, worship services, or

“public service organization” in Section 6)

proselytizing.

Public service for individuals with disabilities

9. Is your employer a governmental organization?

Public service for the elderly

Public health (see definition of “public service

A governmental organization is a Federal, State, local,

organization” in Section 6)

or Tribal government organization, agency, or entity, a

Public education

public child or family service agency, a Tribal college

Public library services

or university, or the Peace Corps or AmeriCorps.

School library services

Yes – Skip to Section 4.

Other school-based services

No – Continue to Item 10.

No – Your employer does not qualify.

SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)

15.

I certify that the information in Section 3 is true, complete, and correct to the best of my knowledge and belief

and that I am an authorized official (see Section 6) of the organization named in Section 3. Complete Items 16 – 21.

Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.

16. Authorized Official’s Name:

19. Authorized Official’s Phone:

____________________________________________

( _______ ) _______ - _____________

17. Authorized Official’s Title:

20. Authorized Official’s Email:

____________________________________________

18. Authorized Official’s Signature:

21. Date:

____________________________________________

___ ___ - ___ ___ - ___ ___ ___ __

Page 2 of 6

Public Service Loan Forgiveness (Pslf): Employment Certification Form Page 2

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