Employment Certification For Public Service Loan Forgiveness (Pslf)
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4Records Code: PSECF-XBCR
OMB No. 1845-0110
Form Approved
Exp. Date 11/30/2014
Employment Certification for Public Service Loan Forgiveness (PSLF)
William D. Ford Federal Direct Loan Program
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents is
subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.
INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS EMPLOYMENT CERTIFICATION
Read the accompanying instructions for completing this Employment Certification for Public Service Loan Forgiveness. Type or print using blue
or black ink. You must sign and date this form in Section 2 and an authorized official from the public service organization which
employs/employed you must completely fill out, sign, and date Section 3. If any information is crossed out or altered in Sections 1 or 2, you must
initial beside the change; any changes in Section 3 must be initialed by your employer.
SECTION 1: BORROWER IDENTIFICATION
Please enter or correct the following information.
Check this box if any of your information has changed.
1a. SSN
-
-
1b. Date of Birth
(MM-DD-YYYY)
-
-
2a. Name
2b. Former Name
Last
First
MI
Last
First
MI
(if applicable)
3. Permanent Address
Street Address
City
State
Zip
Mailing Address
Street Address
City
State
Zip
(if different)
4. Area Code/Telephone – Home (
)
Area Code/Telephone – Other
(
)
5. E-mail (optional)
SECTION 2: BORROWER’S CERTIFICATION REQUESTS, AUTHORIZATIONS, AND UNDERSTANDINGS
Before signing, carefully read the entire form, including the instructions and accompanying letter.
I request that the Public Service Loan Forgiveness servicer, on behalf of the U.S. Department of Education (the Department),
accept this Employment Certification from the public service organization at which I am/was employed for purposes of qualifying
me for the Public Service Loan Forgiveness Program. If I submit this form before I am eligible to apply for forgiveness, I request
that the PSLF servicer retain this certification form until I submit the Application for Public Service Loan Forgiveness.
I authorize my employer(s) or other entities having records about the employment that is part of the basis for my request for
forgiveness to make information from those records available to the Department, including the Public Service Loan Forgiveness
servicer. I also authorize the Department and its respective agents and contractors, to contact me regarding this Employment
Certification, at the current 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) I may only qualify for Public Service Loan Forgiveness after I have made 120 separate, on-time, qualifying monthly payments
on an eligible Direct Loan, after October 1, 2007, while employed full-time by a public service organization(s), or serving in a
full-time AmeriCorps or Peace Corps position, in accordance with the definitions in Section 5. These 120 payments do not
have to be consecutive;
(2) I must be employed full-time by a public service organization(s) or serving in a full-time AmeriCorps or Peace Corps position at
the time I apply for loan forgiveness and at the time the forgiveness is granted. I may be employed part-time concurrently by
more than one eligible public service organization and meet the full-time requirement;
(3) Only the remaining balance of my loan(s) after I have made the 120 separate, on-time, qualifying monthly payments and met
all other eligibility requirements of the PSLF Program may be forgiven;
(4) I am not required to submit any Employment Certification(s) before applying for loan forgiveness, but if I do, the PSLF servicer
will review each Employment Certification I submit to ensure that it is complete, will verify that my employer qualifies as a
public service organization, and that the loan payments I made during the period covered by the Employment Certification(s)
are qualifying payments. Following this review, the PSLF servicer will notify me in writing or electronically of the number of
qualifying payments I have made while employed in qualifying public service and the remaining number I must make before I
am eligible to apply for PSLF. I will also be notified in writing or electronically if the PSLF servicer determines that the form(s) I
submitted is incomplete or that my employment does not meet the qualifying criteria, including the reason(s) for the
determination(s), along with the steps I would need to take to complete this form, correct this information, and submit the
corrected or additional information to the PSLF servicer; and
(5) The Department will only determine whether I have fulfilled all of the requirements to be eligible for PSLF after I have made all
120 qualifying payments and have submitted my loan forgiveness application. I understand that the law does not permit
partial forgiveness based on making a lesser number of qualifying monthly payments while working at a qualifying public
service organization.
Signature of Borrower
Date (MM-DD-YYYY)
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