Fillable Printable Public Service Loan Forgiveness Sample Form
Fillable Printable Public Service Loan Forgiveness Sample Form
Public Service Loan Forgiveness Sample Form
Employment Certification for Public Service Loan Forgiveness (PSLF)
William D. Ford Federal Direct Loan Program
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents is
subject to penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.
INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS EMPLOYMENT CERTIFICATION
Read the accompanying instructions for completing this Employment Certification for Public Service Loan Forgiveness. Type or print using blue
or black ink. You must sign and date this form in Section 2 and an authorized official from the public service organization which
employs/employed you must completely fill out, sign, and date Section 3. If any information is crossed out or altered in Sections 1 or 2, you must
initial beside the change; any changes in Section 3 must be initialed by your employer.
SECTION 1: BORROWER IDENTIFICATION
Please enter or correct the following information.
Check this box if any of your information has changed.
1a. SSN - -
1b. Date of Birth
(MM-DD-YYYY)
- -
2a. Name
Last First MI
2b. Former Name
(if applicable)
Last First MI
3. Permanent Address
Street Address City State Zip
Mailing Address
(if different)
Street Address City State Zip
4. Area Code/Telephone – Home ( ) Area Code/Telephone – Other
( )
5. E-mail (optional)
SECTION 2: BORROWER’S CERTIFICATION REQUESTS, AUTHORIZATIONS, AND UNDERSTANDINGS
Before signing, carefully read the entire form, including the instructions and accompanying letter.
I request that the Public Service Loan Forgiveness servicer, on behalf of the U.S. Department of Education (the Department),
accept this Employment Certification from the public service organization at which I am/was employed for purposes of qualifying
me for the Public Service Loan Forgiveness Program. If I submit this form before I am eligible to apply for forgiveness, I request
that the PSLF servicer retain this certification form until I submit the Application for Public Service Loan Forgiveness.
I authorize my employer(s) or other entities having records about the employment that is part of the basis for my request for
forgiveness to make information from those records available to the Department, including the Public Service Loan Forgiveness
servicer. I also authorize the Department and its respective agents and contractors, to contact me regarding this Employment
Certification, at the current 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) I may only qualify for Public Service Loan Forgiveness after I have made 120 separate, on-time, qualifying monthly payments
on an eligible Direct Loan, after October 1, 2007, while employed full-time by a public service organization(s), or serving in a
full-time AmeriCorps or Peace Corps position, in accordance with the definitions in Section 5. These 120 payments do not
have to be consecutive;
(2) I must be employed full-time by a public service organization(s) or serving in a full-time AmeriCorps or Peace Corps position at
the time I apply for loan forgiveness and at the time the forgiveness is granted. I may be employed part-time concurrently by
more than one eligible public service organization and meet the full-time requirement;
(3) Only the remaining balance of my loan(s) after I have made the 120 separate, on-time, qualifying monthly payments and met
all other eligibility requirements of the PSLF Program may be forgiven;
(4) I am not required to submit any Employment Certification(s) before applying for loan forgiveness, but if I do, the PSLF servicer
will review each Employment Certification I submit to ensure that it is complete, will verify that my employer qualifies as a
public service organization, and that the loan payments I made during the period covered by the Employment Certification(s)
are qualifying payments. Following this review, the PSLF servicer will notify me in writing or electronically of the number of
qualifying payments I have made while employed in qualifying public service and the remaining number I must make before I
am eligible to apply for PSLF. I will also be notified in writing or electronically if the PSLF servicer determines that the form(s) I
submitted is incomplete or that my employment does not meet the qualifying criteria, including the reason(s) for the
determination(s), along with the steps I would need to take to complete this form, correct this information, and submit the
corrected or additional information to the PSLF servicer; and
(5) The Department will only determine whether I have fulfilled all of the requirements to be eligible for PSLF after I have made all
120 qualifying payments and have submitted my loan forgiveness application. I understand that the law does not permit
partial forgiveness based on making a lesser number of qualifying monthly payments while working at a qualifying public
service organization.
Signature of Borrower
Date (MM-DD-YYYY)
Records Code: PSECF-XBCR
OMB No. 1845-0110
Form Approved
Exp. Date 11/30/2014
Page 2 of 4
Borrower Name: _________________________________________ Borrower SSN: |__|__|__|-|__|__|-|__|__|__|__|
SECTION 3: CERTIFICATION OF EMPLOYMENT
See Section 3 of the accompanying Instructions for Completing Employment Certification for Public
Service Loan Forgiveness for detailed information on completing this section.
These Instructions are also located at www.studentaid.ed.gov/publicservice
An authorized official (see Section 5) of the public service
organization at which the borrower is/was employed must
complete this section.
Instructions for Authorized Official:
•
Complete this form only if you are an authorized official of the public service organization at which the borrower identified in Section 1 is/was employed or, if the
borrower is/was a full-time AmeriCorps or Peace Corps volunteer, an authorized official of AmeriCorps or the Peace Corps.
•
Read the definitions in Section 5 before completing this form.
•
Type or print using blue or black ink. All fields must be completed if applicable. Your signature date must include month, day, and year (MM-DD-YYYY).
•
Provide all requested information for Items 1, 2, and 3 below. Complete the employer’s certification at the bottom of this page. The Employment Certification form
cannot be processed if the information requested in this section is missing.
•
If you make any changes to the information you provide in this section, you must initial each change.
Please return the completed form to the borrower. The U.S. Department of Education or the PSLF servicer may contact you for additional information or
documentation.
Instructions for Borrower when there is no Authorized Official:
•
Check this box if you are unable to obtain certification from an authorized official, for example, because the organization no longer exists. Provide all requested
information for Items 1, 2, and 3 below. For Item 1, list the organization’s address from when you worked there, and consult your W2 records for the EIN. The
Department will require you to submit additional evidence of your qualifying employment. Do not submit supporting documents until requested to do so.
1. Information about the public service organization at which the borrower is/was employed.
-
Public Service Organization Name Federally Assigned Employer ID# (EIN)
Public Service Organization Address
2. Borrower’s Employment Status.
(a)
Dates of employment: Start:
- -
End: - -
(MM-DD-YYYY) (If the borrower is still employed, put today’s date)
(b) Borrower’s employment status at your organization:
Full-Time Average number of hours per week: _______
Part-Time Average number of hours per week: _______
For purposes of eligibility for PSLF, full-time employment is defined as:
(1) Working in qualifying employment in one or more jobs for the greater of:
(A) 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
(B) Unless the qualifying employment is with two or more employers, the number of hours the employer considers full-time.
(2) 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.
NOTE: A full-time AmeriCorps or Peace Corps volunteer is considered a full-time employee for eligibility purposes for PSLF.
3. Type of Public Service Organization, in accordance with the definition in Section 5 (check one):
(a)
A government organization (including a Federal, State, local or Tribal organization, agency or entity; a public child or family service agency; or
a Tribal college or university);
(b)
A non-profit, tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code;
(c)
A private, non-profit organization (that is not a labor union or a partisan political organization) that provides at least one of the following public
services (check all that apply):
Emergency management,
Military service,
Public safety,
Law enforcement,
Public interest law services,
Early childhood education (including licensed or regulated child care, Head Start, and State-funded pre-kindergarten),
Public service for individuals with disabilities and the elderly,
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),
Public education,
Public library services,
School library services, or
Other school-based services.
NOTE as to categories (b) and (c): For purposes of the full-time requirement (Section 3, Item 2.(b) above), a borrower’s qualifying employment does not
include time spent on job duties that are related to religious instruction, worship services, or any form of proselytizing.
I certify that the borrower identified in Section 1 above is/was employed at a public service organization, as indicated above, or is/was serving in an
AmeriCorps or Peace Corps position (in accordance with the definitions of these terms in Section 5) during the period identified in Item 2(a) of this section.
Authorized Official’s Name (Printed) Authorized Official’s Title
( )
Authorized Official’s Signature Authorized Official’s Telephone Today’s Date (MM-DD-YYYY)
Page 3 of 4
SECTION 4: ELIGIBILITY REQUIREMENTS / TERMS AND CONDITIONS FOR PUBLIC SERVICE LOAN FORGIVENESS
You may obtain loan forgiveness under this program if:
(1) You are not in default on the loan(s) for which forgiveness is requested.
(2) Except as provided below for AmeriCorps and Peace Corps volunteers, you have made 120 separate, on-time, qualifying monthly payments after October 1, 2007,
on the Direct Loan(s) for which you are requesting forgiveness under one or more of the following repayment plans—
•
The Income-Based Repayment (IBR) Plan;
•
The Income Contingent Repayment (ICR) Plan;
•
The 10-Year Standard Repayment Plan* (Standard Repayment Plan with a maximum 10-year repayment period); 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 Standard
Repayment Plan with a 10-year repayment period may be counted toward the required 120 payments.
In addition, each of the required 120 separate, qualifying monthly payments must have been made on time (no more than 15 days after the scheduled due date)
and for the full scheduled installment amount.
* IMPORTANT: The Standard Repayment Plan for Direct Consolidation Loans entered on or after July 1, 2006 have varying repayment terms based on the loan
amount. For purposes of qualifying for Public Service Loan Forgiveness, monthly payments you make under the Standard Repayment Plan on a Direct
Consolidation Loan are only qualifying payments if made under the 10-year repayment term.
Note for AmeriCorps/Peace Corps volunteers: If you were an AmeriCorps or Peace Corps volunteer, you may receive credit for making qualifying payments if
you make a lump sum payment on an eligible loan for which you are seeking forgiveness by using all or part of a Segal Education Award received after a year of
AmeriCorps service, or by using all or part of a Peace Corps transition payment (if the payment is made within 6 months after you leave the Peace Corps). 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 above; or
(2) Twelve payments.
Peace Corps volunteers making an eligible lump sum payment must do so within 6 months of the End Date, as reported in Section 3 by the authorized official.
(3) You were/are employed full time by one or more public service organizations or serving in a full-time AmeriCorps or Peace Corps position at the time you made
each of the required 120 qualifying monthly payments, at the time you apply for loan forgiveness, and at the time loan forgiveness is granted.
NOTE: You are not permitted to apply the same period of service to receive a benefit under the PSLF Program and the Teacher Loan Forgiveness, Service in Areas
of National Need, and Civil Legal Assistance Attorney Student Loan Repayment Programs.
You may not apply for PSLF until after you have met the eligibility requirements listed above. Since only qualifying payments made after October 1, 2007, while
employed at a qualifying public service organization may be counted toward the required 120 payments, and borrowers may not apply for loan forgiveness until after
they have made all 120 payments, the earliest date that any borrower will be eligible to apply for and receive loan forgiveness is October 2017. A PSLF Application will
be made available to the public before October 2017.
SECTION 5: DEFINITIONS
Eligible Loans
Loans that are eligible for Public Service Loan Forgiveness are:
•
Federal Direct Stafford/Ford Loans (Direct Subsidized Loans)
• Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans)
•
Federal Direct PLUS Loans (Direct PLUS Loans)
• Federal Direct Consolidation Loans (Direct Consolidation Loans).
Loans that are in default are not eligible for forgiveness.
Note: Federal Family Education Loan (FFEL) Program loans, Federal Perkins Loans, and certain Health Professions and Nursing Loans may be consolidated
into a Direct Consolidation Loan. However, payments made on these loans prior to consolidation into the Direct Loan Program are not qualifying
payments and are not counted toward the required 120 payments for PSLF.
Qualifying Payments
Separate, on-time, full monthly payments made after October 1, 2007 under a qualifying Direct Loan repayment plan. A payment is considered on-time if it is
made for the full scheduled installment amount no more than 15 days after the due date for the payment.
Qualifying Direct Loan repayment plans are:
•
The IBR Plan;
•
The ICR Plan;
•
The 10-Year Standard Repayment Plan (Standard Repayment Plan
with a maximum 10-year repayment period); and
•
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
Standard Repayment Plan with a 10-year repayment period may be counted toward the required 120 monthly payments.
Qualifying Employment
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).
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.
An employee means an individual who is hired and paid by a public service organization.
Full-time means working in qualifying employment in one or more jobs for the greater of:
•
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
•
Unless the qualifying employment is with two or more employers, the number of hours the employer considers full time.
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.
Government employee means an individual who is employed by a local, State, Federal, or Tribal government, but does not include a member of the U.S.
Congress.
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.
Military service for uniformed members of 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 in the United States Code, but does not include active duty for training or attendance at a service
Page 4 of 4
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.
Peace Corps position means a full-time assignment under the Peace Corps Act as provided for under 22 U.S.C. 2504.
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.
A public service organization is:
•
A Federal, State, local or Tribal government organization, agency or entity;
•
A public child or family service agency;
•
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;
•
A Tribal college or university; or
•
A private organization (that is not a labor union or a partisan political organization) that provides at least one of the following public services:
•
emergency management,
•
military service,
•
public safety,
•
law enforcement,
•
public interest law services,
•
early childhood education (including licensed or regulated child care, Head Start, and State funded pre-kindergarten),
•
public service for individuals with disabilities and the elderly,
•
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),
•
public education,
•
public library services,
•
school library services, or
•
other school-based services.
NOTE: For purposes of the full-time requirement
(Section 3, Item 2.(b) above)
, an individual borrower’s qualifying employment with a Section 501(c)(3) non-profit or
other private public service organization does not include time spent on job duties that are related to religious instruction, worship services, or any form of proselytizing.
SECTION 6: WHERE TO SEND THE COMPLETED FORM
Send the completed Employment Certification to:
U.S. Department of Education
FedLoan Servicing
P.O. Box 69184
Harrisburg, PA 17106-9184
Or Fax to:
717-720-1628
If you need help completing this form, call:
855-265-4038
If you use a telecommunications device for the deaf (TDD), call:
800-722-8189
Web site: www.MyFedLoan.org
SECTION 7: 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., §451 et seq.,§461 et seq., and §420L et seq. of the Higher Education Act of
1965, as amended (the HEA) (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa et seq., and 20 U.S.C. 1070g 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 §31001(i)(1) of the Debt Collection
Improvement Act of 1996 (31 U.S.C. 7701(c)). Participating in 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 Direct Loan, to
receive a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness), 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 in default. 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.
For a loan, the routine uses of the information that we collect about you include, but are not limited to, its disclosure to federal, state, or local agencies, to institutions of
higher education, and to third party servicers to determine your eligibility to receive a loan, to investigate possible fraud, and to verify compliance with federal student
financial aid program regulations.
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.
For a loan, the routine uses of this information also 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 creditors, to financial and educational institutions, and to guaranty agencies to verify your identity, to
determine your program eligibility and benefits, to permit making, servicing, assigning, collecting, adjusting, or discharging 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, to locate you if you become delinquent in your loan
payments or if you default, or to verify whether your debt qualifies for discharge or cancellation. To provide default rate calculations, disclosures may be made to
guaranty agencies, to financial and educational institutions, or to federal, state or local 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.
Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 0.5 hours (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. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the U.S Department of Education, 400 Maryland Ave., SW, Washington, DC
20210-4537 or e-mail ICDocketMgr@ed.gov and reference OMB Control Number 1845-0110. Note: Please do not return the completed Employment Certification
for Public Service Loan Forgiveness to this address.
If you have comments or concerns regarding the status of your individual submission of this form, contact the PSLF servicer (see Section 6).
