Fillable Printable Public Service Loan Forgiveness Form Sample
Fillable Printable Public Service Loan Forgiveness Form Sample
Public Service Loan Forgiveness Form Sample
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
SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS
Before signing, carefully read the entire form. For more information about PSLF, visit StudentAid.gov/publicservice.
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 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.
Borrower Signature Date
Page 1 of 6
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Name
Address
City, State, Zip Code
Telephone – Primary
E-mail (optional)
Telephone – Alternate
- -
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.
I authorize:
Date of Birth
Former Name (if any)
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.
Page 2 of 6
SECTION 3: EMPLOYMENT INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
Borrower Name: Borrower SSN:
- -
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:
Employer Website (if any):4.
5. Employment Begin Date:
OR
6. Employment End Date:
Still employed.
7. Employment Status:
Full-Time Part-Time
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.
Hours Per Week (Average):
8.
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
AmericCorps.
Is your employer a governmental organization?
9.
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.
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
Public service for individuals with disabilities
Public education
No - Your employer does not qualify.
Other school-based services
School library services
Public library services
Public health (see definition of "public
service organization" in Section 6)
Public service for the elderly
Early childhood education (see definition of
"public service organization" in Section 6)
Public interest legal services (see Section 6)
Law enforcement (see Section 6)
Public safety
Military service (see Section 6)
13. Is your employer a labor union?
Yes - Your employer does not qualify.
No - Continue to Item 14.
12. Is your employer a partisan political organization?
Yes - Your employer does not qualify.
No - Continue to Item 13.
11. Is your employer a not-for-profit organization?
Yes - Continue to Item 12.
No - Your employer does not qualify.
Yes - Skip to Section 4
No - Continue to Item 10
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
.
Authorized Official's Name:
Date:
Authorized Official's Email:
Authorized Official's Phone:16.
Authorized Official's Signature:18.
Authorized Official's Title:17.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
19.
21.
20.
SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM
Page 3 of 6
You may submit information about multiple employers by submitting one copy of Sections 1 and 2 (Page 1), and one
copy of Sections 3 and 4 (Page 2) per employer. When completing this form, type or print using dark ink. Enter dates as
month-day-year (mm-dd-yyyy). Use only numbers. Example: March 14, 2014 = 03-14-2014. If any information is crossed
out or altered in Section 3, it must be initialed by your employer. For more information about PSLF and how to use this
SECTION 6: DEFINITIONS
AmeriCorps position means a position approved by the
Corporation for National and Community Service under
Section 123 of the National and Community Service Act
of 1990 (42 U.S.C. 12573).
o
An annual average of at least 30 hours per week or,
for a contractual or employment period of at least 8
months, an average of 30 hours per week; or
o
Unless the qualifying employment is with two or more
employers, the number of hours the employer
considers full time.
Full-time means working in qualifying employment in
one or more jobs for the greater of:
Peace Corps position
means a full-time assignment under
the Peace Corps Act as provided for under 22
U.S.C. 2504.
Military service for uniformed members of the U.S.
Armed Forces or the National Guard means “active duty”
service or “full-time National Guard duty” as defined in
Section 101(d)(1) and (d)(5) of Title 10 of the United
States Code, but does not include active duty for training
or attendance at a service school. For civilians, military
service means service on behalf of the U. S. Armed
Forces or the National Guard performed by an employee
of a public service organization.
Law enforcement means service performed by an
employee of a public service organization that is publicly
funded and whose principal activities pertain to crime
prevention, control or reduction of crime, or the
enforcement of criminal law.
An on-time payment is a payment made no more than
15 days after the due date for the payment.
An employee means an individual who is hired and paid
by a public service organization.
Eligible loans are loans that are not in default and made
under the William D. Ford Federal Direct Loan (Direct
Loan) Program.
An authorized official is an official of a public service
organization (including AmeriCorps or the Peace Corps)
who has access to the borrower’s employment or service
records and is authorized by the public service
organization to certify the employment status of the
organization’s employees or former employees, or the
service of AmeriCorps or Peace Corps volunteers.
A Tribal college or university; or
o
A public child or family service agency;
o
A Federal, State, local or Tribal government
organization, agency or entity;
o
A non-profit organization under Section 501(c)(3) of
the Internal Revenue Code that is exempt from
taxation under Section 501(a) of the Internal
Revenue Code;
o
A private organization (that is not a business
organized for profit, a labor union, or a partisan
political organization) that provides at least one of
the following public services:
(1)
emergency
management,
(2)
military service,
(3)
public safety,
(4)
law enforcement,
(5)
public interest law services,
(6)
early childhood education (including licensed or
regulated child care, Head Start, and State funded
pre-kindergarten),
(7)
public service for individuals
with disabilities and the elderly,
(8)
public health
(including nurses, nurse practitioners, nurses in a
clinical setting, and full-time professionals engaged
in health care practitioner occupations and health
support occupations, as such terms are defined by
the Bureau of Labor Statistics),
(9)
public education,
(10)
public library services,
(11)
school library
services, or
(12)
other school-based services.
o
A public service organization is:
Public interest law
refers to legal services provided by a
public service organization that are funded in whole or in
part by a local, State, Federal, or Tribal government.
Any other Direct Loan repayment plan, but only if
payments are at least equal to the monthly
payment amount that would be required under
the Standard Repayment Plan with a 10-year
repayment period.
o
The 10-Year Standard Repayment Plan (Standard
Repayment Plan with a maximum 10-year
repayment period); and
o
The Income-Contingent Repayment Plan;
o
The Pay As You Earn Plan;
o
The Income-Based Repayment Plan;
o
Qualifying repayment plans include:
Qualifying employment includes an AmeriCorps
position, a Peace Corps position, or employment at a
public service organization.
Qualifying payments are separate, on-time, full
monthly payments made on a Direct Loan after
October 1, 2007 under a qualifying repayment plan.
form, visit StudentAid.gov/publicservice. Return the completed form to the address shown in Section 7.
SECTION 7: WHERE TO SEND THE COMPLETED FORM
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF
Return the completed form to:
U.S. Department of Education
FedLoan Servicing Or Fax to: 717-720-1628
P.O. Box 69184
Harrisburg, PA 17106-9184
If you need help completing this form, call: 855-265-4038
If you are calling internationally, call: 717-720-1985 If you
use a telecommunication device for the hearing or
speach impaired: (TTY), dial: 711 and enter 800-699-2908
when prompted.
You may obtain loan forgiveness under this program if:
You make 120 qualifying payments (see “Payment
Eligibility”);
On eligible loans (see “Loan Eligibility”);
While working in qualifying employment (see
“Employment Eligibility”).
Payment Eligibility
To receive PSLF, you must make 120 on-time, full,
scheduled, separate monthly payments on your Direct
Loans under a qualifying repayment plan after October 1,
2007.
On-time payments are those that are received by the
Department no later than 15 days after the scheduled
payment due date.
Full payments are payments on your Direct Loan in an
amount that equals or exceeds the amount you are
required to pay each month under your repayment
schedule. If you make a payment that is less than what you
are required to pay for that month, that month's payment
will not count as one of the required 120 qualifying
payments. If you make multiple, partial payments in a
month and the total of those partial payments equals or
exceeds the required full monthly payment amount, those
payments will count as one qualifying payment.
Scheduled payments are those that are made while you are
in repayment. They do not include payments made while
your loans are in an in-school or grace status, in a
deferment or forbearance period, or if your loan is “paid
ahead” because you have made prepayment.
You must make separate monthly payments. Lump sum
payments or payments you make as advance payments for
future months do not count as more than one qualifying
payment. If you wish to make a payment in excess of your
scheduled monthly payment, follow the instructions on
your bill for providing payment instructions, and notate
that your payment is not intended to cover future
installments. Otherwise, your excess payment may affect
your ability to make future qualifying payments.
If you were an AmeriCorps or Peace Corps volunteer, you
may receive credit for making qualifying payments if you
make a lump sum payment by using all or part of a Segal
Education Award or Peace Corps transition payment. The
Department will consider the lump sum payment you
have made as the equivalent of qualifying payments
equal to the lesser of (1) the number of payments
resulting after dividing the amount of the lump sum
payment by the monthly payment amount you would
have made under one of the qualifying repayment plans
listed below; or (2) 12 payments.
Peace Corps volunteers making an eligible lump sum
payment must do so within 6 months of the Employment
End Date, as reported in Section 3.
Your payments must be made under a qualifying
repayment plan. Qualifying repayment plans include:
The Income-Based Repayment (IBR) Plan;
§
§
The Pay As You Earn Repayment Plan;
§
The Income Contingent Repayment (ICR) Plan;
§
The 10-Year Standard Repayment Plan; or
§
Any other Direct Loan repayment plan, but only
payments that are at least equal to the monthly
payment amount that would be required under the
10-Year Standard Repayment Plan.
Though repayment plans other than the IBR, Pay As You
Earn, and ICR Plan are qualifying repayment plans for
PSLF, you must enter IBR, Pay As You Earn, or ICR to
have a remaining balance to forgive after becoming
eligible for PSLF. Otherwise, your loans will be fully
repaid within 10 years. To apply for these plans, visit
StudentLoans.gov.
IMPORTANT: The Standard Repayment Plan for Direct
Consolidation Loans made on or after July 1, 2006 have
repayment periods of different lengths. Monthly
payments you make under the Standard Repayment Plan
on such Direct Consolidation Loans are only qualifying
payments if the loans have a 10-year repayment period
(which would only occur if your total education
indebtedness is less than $7,500).
Loan Eligibility
Only Direct Loan Program loans that are not in default
are eligible for PSLF. Loans you received under the
Federal Family Education Loan (FFEL) Program, the
Federal Perkins Loan (Perkins Loan) Program, or any
other student loan program are not eligible for PSLF.
Page 4 of 6
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SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)
If you have FFEL Program or Perkins Loan Program loans,
you may consolidate them into a Direct Consolidation Loan
to take advantage of PSLF. However, payments made on
your FFEL Program or Perkins Loan Program loans before
you consolidated them, even if they were made under a
qualifying repayment plan, do not count as qualifying PSLF
payments. In addition, if you made qualifying payments on a
Direct Loan and then consolidate it into a Direct
Consolidation Loan, you must start over making qualifying
payments on the new Direct Consolidation Loan. If you
consolidate your FFEL Program or Perkins Loan Program
loans into a Direct Consolidation Loan to take advantage of
PSLF and do not have any Direct Loans, do not submit this
form until you have consolidated your loans. The
application for Direct Consolidation Loans contains a
section that allows you to indicate that you are
consolidating your loans for PSLF. You can consolidate your
you don't know what type of federal student loans you
have, check the National Student Loan Data System (NSLDS)
Employment Eligibility
To qualify for PSLF, you must be an employee of a
qualifying organization. An employee is someone who is
hired and paid by the organization. You may physically
perform your work at a qualifying or non-qualifying
organization, so long as your employer is a qualifying
organization. If you are a contracted employee, the
organization that hired and pays you must qualify, not the
organization where you perform your work. The type or
nature of employment with the organization does not
matter for PSLF purposes.
A qualifying organization is a Federal, State, or local
government agency, entity, or organization or a tax-exempt
organization under Section 501(c)(3) of the Internal
Revenue Code (IRC). Service in an AmeriCorps or Peace
Corps position is also qualifying employment. The type of
services that these organizations provide does not matter
for PSLF purposes.
A private not-for-profit organization that is not a tax-
exempt organization under Section 501(c)(3) of the IRC may
be a qualifying organization if it provides certain specified
public services. These services include emergency
management, military service, public safety, or law
enforcement services; public health services; public
education or public library services; school library and other
school-based services; public interest law services; early
childhood education; public service for individuals with
disabilities and the elderly. The organization must not be a
business organized for profit, a labor union, or a partisan
political organization.
Employment as a member of the U.S. Congress is not
qualifying employment.
You must be employed full-time by your employer.
Generally, you must meet your employer's definition of
full-time. However, for PSLF purposes, that definition
must be at least an annual average of 30 hours per
week. For purposes of the full-time requirement, your
qualifying employment at a 501(c)(3) organization or a
not-for-profit organization does not include time spent
participating in religious instruction, worship services, or
any form of proselytizing.
If you are a teacher, or other employee of a public service
organization, under contract for at least eight out of 12
months, you meet the full-time standard if you work an
average of at least 30 hours per week during the
contractual period and receive credit by your employer
for a full year's worth of employment.
If you are employed in more than one qualifying part-time
job simultaneously, you may meet the full-time
employment requirement if you work a combined average
of at least 30 hours per week with your employers.
Vacation or leave time provided by the employer or leave
taken for a condition that is a qualifying reason for leave
under the Family and Medical Leave Act of 1993, 29,
U.S.C. 2612(a)(1) and (3) is equivalent to hours worked in
qualifying employment.
Other Important Information
The submission of this form before you apply for PSLF is
optional. However, if you wait to submit this form until
you apply for PSLF, you will be required to submit one
form for each employer that you want considered toward
your eligibility for PSLF.
If you submit this form and your employer qualifies, all of
your loans held by the Department will be transferred to
FedLoan Servicing. FedLoan Servicing will then determine
how many qualifying payments you made during the
period of qualifying employment within the dates
provided in Section 3.
You are not permitted to apply the same period of
service to receive PSLF and the Teacher Loan Forgiveness,
Service in Areas of National Need, and Civil Legal
Assistance Attorney Student Loan Repayment programs.
No borrower will be eligible for PSLF until October 2017
at the earliest. An application for PSLF will be made
available at a later time.
federal student loans online by visiting StudentLoans.gov. If
at nslds.ed.gov .
SECTION 9: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 552a)
requires that the following notice be provided to you:
The authorities for collecting the requested information
from and about you are §421 et seq. and §451 et seq. of
the Higher Education Act of 1965, as amended (20 U.S.C.
1071 et seq. and 20 U.S.C. 1087a et seq.) and the
authorities for collecting and using your Social Security
Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20
U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b).
Participating in the Federal Family Education Loan (FFEL)
Program or the William D. Ford Federal Direct Loan
(Direct Loan) Program and giving us your SSN are
voluntary, but you must provide the requested
information, including your SSN, to participate.
The principal purposes for collecting the information on
this form, including your SSN, are to verify your identity,
to determine your eligibility to receive a loan or a benefit
on a loan (such as a deferment, forbearance, discharge, or
forgiveness) under the FFEL and/or Direct Loan Programs,
to permit the servicing of your loan(s), and, if it becomes
necessary, to locate you and to collect and report on your
loan(s) if your loan(s) become delinquent or defaults. We
also use your SSN as an account identifier and to permit
you to access your account information electronically.
The information in your file may be disclosed, on a case-
by-case basis or under a computer matching program, to
third parties as authorized under routine uses in the
appropriate systems of records notices. The routine uses
of this information include, but are not limited to, its
disclosure to federal, state, or local agencies, to private
parties such as relatives, present and former employers,
business and personal associates, to consumer reporting
agencies, to financial and educational institutions, and to
guaranty agencies in order to verify your identity, to
determine your eligibility to receive a loan or a benefit on
a loan, to permit the servicing or collection of your
loan(s), to enforce the terms of the loan(s), to investigate
possible fraud and to verify compliance with federal
student financial aid program regulations, or to locate you
if you become delinquent in your loan payments or if you
default. To provide default rate calculations, disclosures
may be made to guaranty agencies, to financial and
educational institutions, or to state agencies. To provide
financial aid history information, disclosures may be made
to educational institutions. To assist program
administrators with tracking refunds and cancellations,
disclosures may be made to guaranty agencies, to
financial and educational institutions, or to federal or
state agencies. To provide a standardized method for
educational institutions to efficiently submit student
enrollment status, disclosures may be made to guaranty
agencies or to financial and educational institutions. To
counsel you in repayment efforts, disclosures may be
made to guaranty agencies, to financial and educational
institutions, or to federal, state, or local agencies.
In the event of litigation, we may send records to the
Department of Justice, a court, adjudicative body,
counsel, party, or witness if the disclosure is relevant and
necessary to the litigation. If this information, either
alone or with other information, indicates a potential
violation of law, we may send it to the appropriate
authority for action. We may send information to
members of Congress if you ask them to help you with
federal student aid questions. In circumstances involving
employment complaints, grievances, or disciplinary
actions, we may disclose relevant records to adjudicate
or investigate the issues. If provided for by a collective
bargaining agreement, we may disclose records to a
labor organization recognized under 5 U.S.C. Chapter 71.
Disclosures may be made to our contractors for the
purpose of performing any programmatic function that
requires disclosure of records. Before making any such
disclosure, we will require the contractor to maintain
Privacy Act safeguards. Disclosures may also be made to
qualified researchers under Privacy Act safeguards.
Paperwork Reduction Notice. According to the
Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless
such collection displays a valid OMB control number. The
valid OMB control number for this information collection
is 1845-0110. Public reporting burden for this collection
of information is estimated to average 30 minutes per
response, including time for reviewing instructions,
searching existing data resources, gathering and
maintaining the data needed, and completing and
reviewing the collection of information. The obligation to
respond to this collection is required to obtain a benefit
in accordance with 34 CFR 685.219. If you have
comments or concerns regarding the status of your
individual submission of this form, please contact
FedLoan Servicing directly (see Section7).
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