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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 AUTHORIZATIONS, UNDERSTANDINGS** **, AND CERTIFICATION S**  **Before signing, carefully read the entire form** **.** For more information about PSLF, visit StudentAid.gov/publicservice . **I authorize** : **1.** M y 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 age nts 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 automa ted 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 a Direct Loan while employed full -time by a qualifying employer . The 120 qualifying payments do not have to be consecutive . **2.** To qualify for PSLF, I must be employed full -time by a qualifying employer 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 will be forgiven . **4.** By submitting this form, my student loans 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 of the number of qualifying payments I have made while employed full time by a qualifying employer 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 electronica lly 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 . **I certify** that: **1.** A ll 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. **2.** I cannot obtain certification from my employer because the organization is closed or because the organization has refused to certify my employment . The Department will follow up to attempt to assi st me in getting documentation of my employment . **Complete Section 3, but do not complete Section 4** **. 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 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):

_________ ______ ___ Inc lude vacation, leave time, or any leave taken under 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 is 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 – Have your employer complete 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 – Have your employer complete Section 4 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 eligible . 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 the services your employer provides . Have your employer complete 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 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 16**  **– 21**  **. 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:

___ ___ - ___ ___ - ___ ___ ___ __Page 3 of 6 **SECTION 5**  **: INSTRUCTIONS FOR COMPLETING THE FORM**  You may submit information about multiple employers by submitting one copy of Sections 1 and 2 (Pa ge 1) and one copy of Section s 3 and 4 (Page 3) 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 = 02 - 10- 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 form, visit . **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 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 organizat ion’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 wh o 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 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 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 trainin g 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 .  **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 Triba l 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 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 occupati ons 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 .  **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, a 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 Plan 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 To receive PSLF, 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 the Department no later than 15 days after th e 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, th ose 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 payme nt in excess of your schedule d 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 ma ke future qualifying payments . I f 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) 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 Employment End Date, as reported in Section 3 . Your payments must be made unde r 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 qu alifying 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 with in 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 . M onthly payments you make under t he Standard Repayment Plan on such Direct Consolidation Loan s are only qualifying payments if the loan s have a 10-year repayment period (only if your total education indebtedness is less than $7,500) . Loan Eligibility Only Direct Loan Program loans that a re 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 qualifyi ng 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 Consolidat ion Loan .Page 5 of 6 **SECTION 7: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)**  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 . T he application for the consolidation loan contains a section that allows you to indicate that you are consolidating your loans for PSLF . You can consolidate 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 System (NSLDS) at nslds . ed . gov . 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 . 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 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. T he 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 p ublic 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 we ek . 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 e mployee 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 payment you made during the period of qualifying employ ment represented by the employment dates provided in Section 3. 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 p rograms . 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. **SECTION 8**  **: WHERE TO SEND THE COMPLETED FORM**  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 Will iam 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 in formation 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 guara nty 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 educat ional 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 agenc ies, to financial and educational institutions, or to federal or state agencies . To provide a standardized method for educational institutions to efficiently submit student enrollment statuses, disclosures may be made to guaranty agencies or to financial a nd 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 Depa rtment 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 safeg uards . **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 inform ation 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 con tact FedLoan Servicing directly (See Section 8) .