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PUBLIC SERVICE LOAN FORGIVENESS (PSLF):

OMB No. 1845-0110

Form Approved

APPLICATION FOR FORGIVENESS

Exp. Date 5/31/2020

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

PSFAP - XBCR

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

PSLF APP

the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: BORROWER INFORMATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN

Date of Birth

Name

Address

City

State

Zip Code

Telephone - Primary

Telephone - Alternate

Email (Optional)

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

this form only if you (1) have Direct Loans, (2) made 120 qualifying payments on the Direct Loans for which you are seeking

forgiveness, and (3) worked, and continue to work, full-time at a qualifying employer when you made the qualifying

payments. If the employment certified in Sections 3 and 4 of this application does not cover all 120 qualifying payments, you

must submit a copy of Section 3 and 4 (page 2) for each qualifying employer that covers the rest of your qualifying payments.

SECTION 2: BORROWER REQUEST, UNDERSTANDINGS, CERTIFICATION, AND AUTHORIZATION

I request (1) that the U.S. Department of Education (the Department) forgive the remaining balance of my Direct Loans and

(2) if I submit employment certification covering 10 years of qualifying employment after October 1, 2007, a forbearance on

my Direct Loans while the Department determines my eligibility for forgiveness, unless I indicate otherwise below.

By checking this box, I am indicating that I do not want a forbearance while my application is being processed.

I understand that:

1. To qualify for PSLF, I must have made 120 qualifying payments on my Direct Loans 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 when I apply for and receive PSLF.

3. By submitting this form, my student loans held by the Department will be transferred to FedLoan Servicing.

4. If the Department determines that I appear to be eligible for forgiveness, the Department may contact my employer

before granting forgiveness to ensure that I continue to work for the employer.

5. If I am eligible for forgiveness, the amount forgiven will be the principal and interest that was due on my eligible Direct

Loans when I made my final qualifying payment. Any amount that I pay on those loans after I have made my final

qualifying payment will be treated as an overpayment. I must continue to make payments on any of my other loans.

6. If I am not eligible for forgiveness, I will be notified of the determination and why it was made, my forbearance will end,

and unpaid interest may be capitalized (added to my loan's principal balance).

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 and that if I cease to be employed by a qualifying employer after I submit this

application, but before forgiveness is granted, I will notify the Department (see Section 7) immediately.

I authorize 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.

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.

Date

Borrower's Signature

Page 1 of 6

Application For Forgiveness - Public Service Loan Forgiveness (Pslf) - U.s. Department Of Education

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