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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 CERTIFICATIONS

Before signing, carefully read the entire form. For more information about PSLF, visit StudentAid.gov/publicservice. 

I authorize:

1. My employer or other entity having records about the employment that is the basis of my request to make 

information from those records available to the U. S. Department of Education (the Department) or its agents or 

contractors. 

2. The Department (and its agents or contractors) to contact me regarding my request or my loan(s), including 

repayment of my loan(s), at the telephone number that I provide on this form or any future number that I provide 

for my cellular telephone or other wireless device using automated telephone dialing equipment or artificial or 

prerecorded voice or text messages. 

I understand that:

1. To qualify for PSLF, I must make 120 qualifying payments on 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 fulltime 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 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. 

I certify that:

1. 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. 

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 assist me in getting 

documentation of my employment. Complete Section 3, but do not complete Section 4. 

Borrower Signature _______________________________________________ Date ___ ___ - ___ ___ - ___ ___ ___ __
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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): __________________

Include vacation, leave time, or any leave taken under 

the Family Medical 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:

___ ___ - ___ ___ - ___ ___ ___ __
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SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM

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 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 

organization’s employees or former employees, or the 

service of AmeriCorps or Peace Corps volunteers. 

 Eligible loans 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 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 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. 

 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 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. 

 Qualifying payments 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. 
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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 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 (only 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. 

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. 
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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. The 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 qualifying organization is a Federal, State, or local 

government agency, entity, or organization or a taxexempt 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 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 

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 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 

payment you made during the period of qualifying 

employment 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 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.

SECTION 8: WHERE TO SEND THE COMPLETED FORM

Return the completed form to: If you need help completing this form, call:
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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 caseby-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 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 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 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 (See Section 8).