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Fillable Printable Public Service Loan Forgiveness Form - Employment Certification Form

Fillable Printable Public Service Loan Forgiveness Form - Employment Certification Form

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
MO
63110
314
5555555
janedoe@email.com
X
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
X
X
45
X
X
Jerry S. Official
Human Resources Supervisor
jerry.s.official@slps.edu
314
5555555
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