Employment Certification For Public Service Loan Forgiveness (Pslf) Page 2

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Borrower Name: _________________________________________

Borrower SSN: |__|__|__|-|__|__|-|__|__|__|__|

SECTION 3: CERTIFICATION OF EMPLOYMENT

An authorized official (see Section 5) of the public service

See Section 3 of the accompanying Instructions for Completing Employment Certification for Public

organization at which the borrower is/was employed must

Service Loan Forgiveness for detailed information on completing this section.

complete this section.

These Instructions are also located at

Instructions for Authorized Official:

• Complete this form only if you are an authorized official of the public service organization at which the borrower identified in Section 1 is/was employed or, if the

borrower is/was a full-time AmeriCorps or Peace Corps volunteer, an authorized official of AmeriCorps or the Peace Corps.

• Read the definitions in Section 5 before completing this form.

• Type or print using blue or black ink. All fields must be completed if applicable. Your signature date must include month, day, and year (MM-DD-YYYY).

• Provide all requested information for Items 1, 2, and 3 below. Complete the employer’s certification at the bottom of this page. The Employment Certification form

cannot be processed if the information requested in this section is missing.

• If you make any changes to the information you provide in this section, you must initial each change.

Please return the completed form to the borrower. The U.S. Department of Education or the PSLF servicer may contact you for additional information or

documentation.

Instructions for Borrower when there is no Authorized Official:

•

Check this box if you are unable to obtain certification from an authorized official, for example, because the organization no longer exists. Provide all requested

information for Items 1, 2, and 3 below. For Item 1, list the organization’s address from when you worked there, and consult your W2 records for the EIN. The

Department will require you to submit additional evidence of your qualifying employment. Do not submit supporting documents until requested to do so.

1. Information about the public service organization at which the borrower is/was employed.

Public Service Organization Name

Federally Assigned Employer ID# (EIN)

Public Service Organization Address

2. Borrower’s Employment Status.

(a) Dates of employment:

Start:

End:

(MM-DD-YYYY)

(If the borrower is still employed, put today’s date)

(b) Borrower’s employment status at your organization:

Full-Time

Average number of hours per week: _______

Part-Time

Average number of hours per week: _______

For purposes of eligibility for PSLF, full-time employment is defined as:

(1) Working in qualifying employment in one or more jobs for the greater of:

(A) An annual average of at least 30 hours per week or, for a contractual or employment period of at least 8 months, an average of 30 hours per

week; or

(B) Unless the qualifying employment is with two or more employers, the number of hours the employer considers full-time.

(2) Vacation or leave time provided by the employer or leave taken for a condition that is a qualifying reason for leave under the Family and Medical

Leave Act of 1993, 29 U.S.C. 2612(a)(1) and (3) is equivalent to hours worked in qualifying employment.

NOTE: A full-time AmeriCorps or Peace Corps volunteer is considered a full-time employee for eligibility purposes for PSLF.

3. Type of Public Service Organization, in accordance with the definition in Section 5 (check one):

(a)

government organization

(including a Federal, State, local or Tribal organization, agency or entity; a public child or family service agency; or

a Tribal college or university);

(b)

non-profit, tax-exempt organization

under Section 501(c)(3) of the Internal Revenue Code;

(c)

private, non-profit organization

(that is not a labor union or a partisan political organization) that provides at least one of the following public

services (check all that apply):

Emergency management,

Military service,

Public safety,

Law enforcement,

Public interest law services,

Early childhood education (including licensed or regulated child care, Head Start, and State-funded pre-kindergarten),

Public service for individuals with disabilities and the elderly,

Public health (including nurses, nurse practitioners, nurses in a clinical setting, and full-time professionals engaged in health care

practitioner occupations and health support occupations, as such terms are defined by the Bureau of Labor Statistics),

Public education,

Public library services,

School library services, or

Other school-based services.

NOTE as to categories (b) and (c): For purposes of the full-time requirement (Section 3, Item 2.(b) above), a borrower’s qualifying employment does not

include time spent on job duties that are related to religious instruction, worship services, or any form of proselytizing.

I certify that the borrower identified in Section 1 above is/was employed at a public service organization, as indicated above, or is/was serving in an

AmeriCorps or Peace Corps position (in accordance with the definitions of these terms in Section 5) during the period identified in Item 2(a) of this section.

Authorized Official’s Name (Printed)

Authorized Official’s Title

(

)

Authorized Official’s Signature

Authorized Official’s Telephone

Today’s Date (MM-DD-YYYY)

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