Fillable Printable Public Service Loan Forgiveness Form - Employment Certification Form

Public Service Loan Forgiveness Form - Employment Certification Form

PUBLIC SERVICE LOAN FORGIVENESS (PSLF):

EMPLOYMENT CERTIFICATION FORM

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

OMB No. 1845-0110

Form Approved

Exp. Date 12/31/2017

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 the U. S. Criminal

Code and 20 U. S. C. 1097.

SECTION 1: BORROWER IDENTIFICATION

Please enter or correct the following information.

Check this box if any of your information has changed.

SSN

Date of Birth

Name

Former Name (if any)

Address

City, State, Zip

Telephone – Primary

Telephone – Alternate

E-mail (optional)

_0_ _0_ _0_ - _0_ _0_ - _0_ _0_ _0_ _0_

_Ϭ_ _ϭ_ - _Ϭ_ _ϭ_ - _ϭ_ _ϵ_ _ϴ_ _Ϭ__

___________________________________________

________________________ , _______ __________

( ___________ ) ___________ - _________________

___________________________________________

SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS

I authorize:

1. 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.

2. The Department (and its agents or contractors) to contact me regarding my request or my loan(s), including

repayment of my loan(s), at the telephone number that I provide on this form 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. To qualify for PSLF, I must make 120 qualifying payments on my Direct Loan(s) 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 or employers when I apply for PSLF and

when my loan is forgiven.

3. If I qualify for forgiveness, only the remaining balance on my Direct Loan(s) will be forgiven.

4. By submitting this form, my student loan(s) held by the Department will be transferred to FedLoan Servicing.

5. The Department may request supplemental documentation substantiating my employment.

6. The Department will notify me in writing or electronically of the number of qualifying payments I have made while

employed full-time by a qualifying employer or employers and the remaining number of qualifying payments I

must make before I am eligible to apply for PSLF.

7. The Department will notify me in writing or electronically if the form that I submit is incomplete, or if it

determines that my employment or payments do not qualify for PSLF. The Department will explain the reason for

the determination and the steps I need to take to correct the form or make qualifying payments.

8. The Department will retain this certification form until I submit my application for forgiveness.

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.

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.

Borrower Signature _______________________________________________ Date ___ ___ - ___ ___ - ___ ___ ___ __

Jane Doe

1234 Main St

Saint Louis

63110

314

555 5555

[email protected]

Borrower Name: ___________________________________ Borrower SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 3: EMPLOYMENT INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)

1. Employer Name: ______________________________

____________________________________________

2. Federal Employer Identification Number (EIN):

___ ___ - ___ ___ ___ ___ ___ ___ ___

Your employer’s EIN may be found on your Wage and

Tax Statement (W-2).

3. Employer Address:

____________________________________________

4. Employer Website (if any)

____________________________________________

5. Employment Begin Date:

___ ___ - ___ ___ - ___ ___ ___ ___

6. Employment End Date:

___ ___ - ___ ___ - ___ ___ ___ ___ OR

Still employed.

7. Employment Status: Full-Time Part-Time

8. Hours Per Week (Average): __________________

Include vacation, leave time, or any leave taken under

the Family Medical Leave Act of 1993. If your

employer is a 501(c)(3) or a not-for-profit

organization, do not include any hours you spent on

religious instruction, worship services, or

proselytizing.

9. Is your employer a governmental organization?

A governmental organization is a Federal, State, local,

or Tribal government organization, agency, or entity, a

public child or family service agency, a Tribal college

or university, or the Peace Corps or AmeriCorps.

Yes – Skip to Section 4.

No – Continue to Item 10.

10. Is your employer a tax-exempt organization under

section 501(c)(3) of the Internal Revenue Code?

Yes – Skip to Section 4

No – Continue to Item 11.

11. Is your employer a not-for-profit organization?

Yes – Continue to Item 12.

No – Your employer does not qualify.

12. Is your employer a partisan political organization?

Yes – Your employer does not qualify.

No – Continue to Item 13.

13. Is your employer a labor union?

Yes – Your employer does not qualify.

No – Continue to Item 14.

14. Does your employer provide any of the below

services?

Yes – Select all the services your employer

provides and then continue to Section 4.



Emergency management



Military service (see Section 6)



Public safety



Law enforcement (see Section 6)



Public interest legal services (see Section 6)



Early childhood education (see definition of

“public service organization” in Section 6)



Public service for individuals with disabilities



Public service for the elderly



Public health (see definition of “public service

organization” in Section 6)



Public education



Public library services



School library services



Other school-based services

No – Your employer does not qualify.

SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)

15. 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 Items 16 – 21.

Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.

16. Authorized Official’s Name:

____________________________________________

17. Authorized Official’s Title:

____________________________________________

18. Authorized Official’s Signature:

____________________________________________

19. Authorized Official’s Phone:

( _______ ) _______ - _____________

20. Authorized Official’s Email:

____________________________________________

21. Date:

___ ___ - ___ ___ - ___ ___ ___ __

Jane Doe

0 0 0 0 0 0 0 0 0

Saint Louis Elementary

1 1 1 1 1 1 1 1 1

801 N. Eleventh St, Saint Louis MO 63102

www.slps.edu

0 1 0 1 2 0 0 7

Jerry S. Official

Human Resources Supervisor

jerry.s.official@slps.edu

314

555 5555