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## PUBLIC SERVICE LOAN FORGIVENESS (PSLF) **: EMPLOYMENT CERTIFICATION**  **FORM William D. Ford Federal Direct Loan (Direct Loan) Program**  OMB No. 1845 -0110 DRAFT FORM Exp. Date XX/XX/XXXX **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) ___ ___ ___ - ___ ___ - ___ ___ ___ ___

___ ___ - ___ ___ - ___ ___ ___ ___

_____________________________ _______ _______

____________________________________ _______

____________________________________ _______ (

____ ____ ___ )

___ ____ ____ - ___

_ _ ___ _________ (

_ ___ _ _ __ ___ )

_____

____ __ - _____

_ _ ___ _______

_____________________________ _______ _______

___________________________________________ **SECTION 2: BORROWER REQUEST, AUTHORIZATIONS, UNDERSTANDINGS** **, AND CERTIFICATION Before signing, carefully read the entire form, including**  **the instructions and any accompanying**  **information .**  **I request** that the PSLF servicer (FedLoan Servicing) , on behalf of the U.S. Department of Education (the Department), accept this Employment Certification form from the public service organization at which I am/was employed for the purposes of determining whether my employment and Direct Loan payments qualify for PSLF, and retain this certification form until I submit my PSLF application . **I aut horize**  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 Department, including FedLoan Servicing. I also authorize 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 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.** I may only qualify for PSLF after I have made 120 qualifying payments on a Direct Loan while employed full -time by a qualifying employer . The 120 qualifying payments do not have to be consecutive. **2.** I must be employed full -time by a qualifying employer when I apply for PSLF and when I am granted PSLF. **3.** If I qualify for forgiveness, only the remaining balance on my Direct Loan will be forgiven. The law does not permit partial forgiveness based on making fewer than 120 qualifying payments. **4.** I am not required to submit an Employment Certification form before applying for forgiveness. **5.** By submitting this form, my student loans held by the Department w ill be transferred to the FedLoan Servicing. **6.** FedLoan Servicing may request supplemental documentation substantiating my employment. **7.** FedLoan Servicing will notify me in writing or electronically of the number of qualifying payments I have made while employe d full -time by a qualifying employer and the remaining number of qualifying payments I must make before I am eligible to apply for PSLF. **8.** FedLoan Servicing will notify me in writing or electronically if the form that I submit is incomplete, or if it determ ines that my employment or payments do not qualify for PSLF, including the reason for the determination and the steps I need to take to correct the form or make qualifying payments . **9.** The Department will only determine whether I have fulfilled all of the requirements for PSLF after I have made 120 qualifying payments and have submitted my PSLF application. **I certify** that that all of the information I have provided on this form and in any accompanying documentation is true, complete, and correct to the best of my knowledge and belief. **Borrower Signature**

_______________________________________________ **Date**

___ ___ - ___ ___ - ___ ___ ___ __Page 2 of 6 **Borrower Name:**

___________________________________ **Borrower SSN:**

___ ___ ___ - ___ ___ - ___ ___ ___ ___ **SECTION 3: EMPLOYMENT**  **INFORMATION 1.**  Employer Name:

__

___ ____ _______ ___ ________ ___

___________________________ ___ ______________ **2.** Federal Employer Identification Number (EIN) :

___ ___ - ___ ___ ___ ___ ___ ___ ___ Your EIN may be found on your 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):

_________ ______ ___ Inc lude vacation, leave time, or any leave taken unde r the Family Me dical Leave Act of 1993 . If your employer is 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 includes a Federal, State, local, or Tribal 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 Item 15 . 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 Item 15 . No – Continue to Item 11 . **11.** Is your employer a **not -** **for -**  **profit** organization? Yes – Continue to Item 12 . No – Your employer is not eligible . **12.** Is your employer a partisan political organization? Yes – Your employer is not eli gible . No – Continue to Item 13 . **13.** Is your employer a labor union? Yes – Your employer is not eligible . No – Continue to Item 14 . **14.** Does your employer provide any of the below services? Yes – Select all services your employer provides and then skip to Item 15 .  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**  **CERTIFICA TION**  **15.** I certify that the borrower is/was employed at the organization identified in Section 3, for which I am an authorized official (as defined in Section 6 ) , during the period identified in Section 3 . **Complete Items 17**  **– 22**  **. 16.**  I certify that I, the borrower, cannot obtain certification from my employer because the o rganization is closed or because the organization has refused to certify my employment . FedLoan Servicing will follow up to request documentation of my employment . **Skip Items 17**  **– 22**  **. 17.**  Authorized Official ’s Name:

__________________________________ ___ _______ **18.** Authorized Official ’s Title:

__________________________________ ___ _______ **19.** Authorized Official ’s Signature:

__________________________________ ___ _______ **20.** Authorized Official ’s Phone:

(

_______ )

_______ - _____________ **21.** Authorized Official ’s Email:

_________

___ _________

_______________________ **22.** Date:

___ ___ - ___ ___ - ___ ___ ___ ___Page 3 of 6 **SECTION 5**  **: INSTRUCTIONS FOR COMPLETING THE FORM** 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 = 02 - 10- 2014. If any information is crossed out or altered in Section 3, it must be initialed by your employer. You may submit this form more or less frequently than annually to cover more or less than one year’s employment . However, FedLoan Servicing will only determine that a payment qualifies if it was made during a period of qualifying employment that is documented on this form. For more information about PSLF and how to use this form, visit StudentAid.gov/publicservice . **Return the completed form to the address shown in Section 8**  **. 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).  An **authorized official** is an official of a public service organization (including AmeriC orps 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 AmeriCo rps or Peace Corps volunteers.  **Eligible l oans**  are loans that are not in default and made under the William D. Ford Federal Direct Loan (Direct Loan) Program.  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: o Unless the qualifying employment is with two or more employers, the number of hours the employer considers full time. 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  An **on -** **time payment** is a payment made no more than 15 days after the due date for the payment.  **Law enforcement** means service performed by an employee of a public serv ice 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 school . For civilians, military service mean s 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: o A Federal, State, local or Tribal government organization, agency or entity; o A public child or family service agency; 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 Tribal college or university; or o A privat e organization (that is not 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)** pub lic library services, **(11)** school library services, or **(12)** other school - based services.  **Qualifying p ayments**  are separate, on -time, full monthly payments made on a Direct Loan after October 1, 2007 under a qualifying repayment plan.  **Qualifying employment** includes an AmeriCorps position, Peace Corps position, or employment at a public service organization.  **Qualifying repayment plans** include : o The Income - Based Repayment Plan; o The Pay As You Earn Plan; o The Income - Contingent Repayment Plan; o The 10-Year Standard Repayment Plan (Standard Repayment Plan with a maximum 10-year repayment period); and o 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 P lan with a 10-year repayment period.Page 4 of 6 **SECTION 7**  **: IMPORTANT INFORMATION ABOUT PSLF**  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 You must make 120 on -time, full, scheduled, separate month ly payments on your Direct Loans under a qualifying repayment plan after October 1, 2007 . On -time payments are those that are received by your federal loan servicer 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 yo u 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, p artial 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 sta tus, in a deferment or forbearance period , or if your loan is “paid ahead” more than one full month because you have made prepayments . You must make separate monthly payments. Lump sum payments or payments you make as advance payments for future months will not count as more than one qualifying payments. If you wish to make a payment in excess of your schedule d monthly payment, follow your loan servicer’s instructions for provid ing 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 . I f you were an AmeriCorps or Peace Corps volunteer, you may rece ive 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 paym ents equal to the lesser of (1) t he num b er 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 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;  Th e 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 qu alifying repayment plans for PSLF, you must enter IBR, Pay As You Earn, or ICR to have a remaining balance to forgive aft er becoming eligible for PSLF. 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 . M onthly payments you make under t he Standard Repayment Plan on such Direct Consolidation Loan s are only qualifying payme nts if the loan s have a 10-year repayment period. Loan Eligibility Only loans you received under the Direct Loan Program and 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. 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, p ayments 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 .Page 5 of 6 **SECTION 7: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)**  If you c onsolidate your FFEL Program or Perkins Loan Program loans to take advantage of PSLF and do not have any Direct Loans , do not submit this form until your have consolidated your loans. If you consolidate your loans, the application contains a section that w ill allow you to indicate that you are consolidating your loans for PSLF. If you indicate that you are consolidating your loans for PSLF, your consolidation application will be routed to the PSLF Servicer, FedLoan Servicing, for processing. You can consoli date your federal student loans online by visiting StudentLoans.gov . If you don't know what type of federal student loans you have, check the National Student Loan Data Syst em (NSLDS) at nslds.ed.gov . Employment Eligibility 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 qua lifying or non - qualifying organization, so long as your employer is a qualifying organization. The type or nature of employment with the organization does not matter for PSLF purposes. A q ualifying organization is a F ederal , State , or local government agency, entity, or organization , service in an AmeriCorps or Peace Corps position, or a tax- exempt organization under Section 501(c)(3) of the Internal Revenue Code (IRC). Additionally, the type of services that these organizations provide does not matter for PSLF purposes. A private not -for- profit organization that is not a taxexempt 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 managemen t, 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 fo r individuals with disabilities and the elderly. The organization must not be 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 . G enerally, 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 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 sim ultaneously, 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 You must be employed at a qualifying organization at the time you make each of the 120 qualifying payments and at the time that you apply for and receive loan forgiveness . 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.

**SECTION 8**  **: WHERE TO SEND THE COMPLETED REQUEST** Return the completed form to : If you need help completing this form, call:Page 6 of 6 **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) becomes 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, prese nt 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 mad e 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 met hod for educational institutions to efficiently submit student enrollment statuses, 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 ne cessary 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 sources, 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 ( 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.