Application For Forgiveness - Public Service Loan Forgiveness (Pslf) - U.s. Department Of Education Page 2
ADVERTISEMENT
1
2
3
4
5
6Borrower Name
Borrower SSN
SECTION 3: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
1. Employer Name:
10. Is your employer tax-exempt under Section 501(c)(3)
of the Internal Revenue Code (IRC)?
If your employer is tax-exempt under another
subsection of 501(c) of the IRC, such as 501(c)(4) or
2. Federal Employer Identification Number (FEIN)
501(c)(6), check "No" to this question.
Yes - Skip to Section 4.
Your employer's Federal EIN may be found on your
No - Continue to Item 11.
Wage and Tax Statement (W-2).
11. Is your employer a not-for-profit organization that is
3. Employer Address:
not tax-exempt under Section 501(c)(3) of the Internal
Revenue Code?
Yes - Continue to Item 12.
No - Your employer does not qualify.
4. Employer Website (if any):
12. Is your employer a partisan political organization or a
labor union?
Yes - Your employer does not qualify.
No - Continue to Item 13.
5. Employment Begin Date:
13. Which of the following services does your employer
provide as its primary purpose? Check all that apply
6. Employment End Date:
and then continue to Section 4. If you you check
"None of the above", do not submit this form.
Still Employed
OR
Emergency management
7. Employment Status:
Full-Time
Part-Time
Military service (See Section 6)
Public safety
8. Hours Per Week (Average)
Law enforcement
Include vacation, leave time, or any leave taken
Public interest legal services (See Section 6)
under the Family Medical Leave Act of 1993. If your
employer is a 501(c)(3) or a not-for-profit organization,
Early childhood education (See Section 6)
do not include any hours you spent on religious
Public service for individuals with disabilities
instruction, worship services, or proselytizing.
Public service for the elderly
9. Is your employer a governmental organization?
Public health (See Section 6)
A governmental organization is a Federal, State,
Public education (See Section 6)
local, or Tribal government organization, agency, or
Public library services
entity, a public child or family service agency, a Tribal
college or university, or the Peace Corps or
School library services
AmeriCorps.
Other school-based services
Yes - Skip to Section 4.
None of the above - the employer does not
No - Continue to Item 10.
qualify.
SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)
By signing, I certify (1) that the information in Section 3 is true, complete, and correct to the best of my knowledge and
belief, (2) that I am an authorized official (see Section 6) of the organization named in Section 3, and (3) that the borrower
named in Section 1 is or was an employee of the organization named in Section 3.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
Official's Name
Official's Phone
Official's Title
Official's Email
Date
Authorized Official's Signature
Page 2 of 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Financial Disclosure For Reasonable And Affordable Rehabilitation Payments Form - U.s. Department Of Education
Legal
Form Hud-92001-a - Application For Federal Housing Administration (fha) Lender Approval - U.s. Department Of Housing And Urban Development
Legal
Form Op-1 - Application For Motor Property Carrier And Broker Authority - U.s. Department Of Transportation
Legal
Heal Form 539 - Physician's Certification Of Borrower's Total And Permanent Disability - U.s. Department Of Education
Legal
Early Childhood Program Participation, From The National Household Education Surveys Program Of 2012 - U.s. Department Of Education
Legal
Related Categories
Parent category: Legal