Public Service Loan Forgiveness (Pslf): Employment Certification Form Page 2
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6Borrower Name
Borrower SSN
SECTION 3: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
10. Is your employer tax-exempt under Section 501(c)(3)
1. Employer Name:
of the Internal Revenue Code?
Yes - Skip to Section 4.
2. Federal Employer Identification Number (FEIN)
No - Continue to Item 11.
11. Is your employer a not-for-profit organization?
Your employer's EIN may be found on your Wage
Yes - Continue to Item 12.
and Tax Statement (W-2).
No - Your employer does not qualify.
3. Employer Address:
12. Is your employer a partisan political organization?
Yes - Your employer does not qualify.
No - Continue to Item 13.
4. Employer Website (if any):
13. Is your employer a labor union?
Yes - Your employer does not qualify.
5. Employment Begin Date:
No - Continue to Item 14.
14. Indicate which service or services your employer
6. Employment End Date:
provides and then continue to Section 4, if
appropriate:
OR
Emergency management
Still Employed
Military service (See Section 6)
Public safety
7. Employment Status:
Full-Time
Part-Time
Law enforcement
8. Hours Per Week (Average)
Public interest legal services (See Section 6)
Include vacation, leave time, or any leave taken
Early childhood education (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,
Public service for individuals with disabilities
do not include any hours you spent on religious
Public service for the elderly
instruction, worship services, or proselytizing.
Public health (See Section 6)
9. Is your employer a governmental organization?
Public education (See Section 6)
A governmental organization is a Federal, State,
Public library services
local, or Tribal government organization, agency, or
School library services
entity, a public child or family service agency, a Tribal
college or university, or the Peace Corps or
Other school-based services
AmeriCorps.
None of the above - your employer does not
Yes - Skip to Section 4.
qualify.
No - Continue to Item 10.
SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)
By signing, 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 the rest of this Section.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
Authorized Official's Name
Authorized Official's Phone
Authorized Official's Email
Authorized Official's Title
Date
Authorized Official's Signature
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