Form PSLF ECF "Public Service Loan Forgiveness (Pslf): Employment Certification Form"

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Download Form PSLF ECF "Public Service Loan Forgiveness (Pslf): Employment Certification Form"

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PUBLIC SERVICE LOAN FORGIVENESS (PSLF):
OMB No. 1845-0110
Form Approved
EMPLOYMENT CERTIFICATION FORM
Exp. Date 5/31/2020
William D. Ford Federal Direct Loan (Direct Loan) Program
PSECF - XBCR
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
PSLF ECF
the U.S. Criminal Code and 20 U.S.C. 1097.
SECTION 1: BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Date of Birth
Name
Address
City
State
Zip Code
Telephone - Primary
Telephone - Alternate
Email (Optional)
SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATION
Before signing, carefully read the entire form. For more information on 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 entity to which I submit this request and its agents to contact me regarding my request or my loans at any cellular
telephone number that I provide now or in the future 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 my Direct Loans while employed full-time by a qualifying
employer or employers. Neither the 120 qualifying payments nor the employment have to be consecutive.
2. To qualify for PSLF, I must be employed full-time by a qualifying employer when I apply for and receive PSLF.
3. If I qualify for forgiveness, only the remaining balance on my Direct Loans will be forgiven.
4. By submitting this form, my student loan(s) held by the Department will be transferred to FedLoan Servicing.
5. The Department may request supplemental documentation substantiating my employment.
6. The Department will notify me in writing or electronically of the number of qualifying payments I have made while
employed full-time by a qualifying employer and how many more I must make before I am eligible to apply for PSLF.
7. I will be notified if the form that I submit is incomplete, or if my employment or payments do not qualify for PSLF, why
the determination was made, and the steps I need to take to correct the form or make qualifying payments.
8.
The Department will retain this certification form until I submit my application for forgiveness.
I certify that all of the information I have provided on this form and in any accompanying document is true, complete, and
correct to the best of my knowledge and belief.
Check this box if you cannot obtain certification from your employer because the organization is closed or because the
organization has refused to certify your employment. The Department will follow up to assist you in getting
documentation of your employment. Complete Section 3, but do not complete Section 4.
Date
Borrower's Signature
Page 1 of 6
PUBLIC SERVICE LOAN FORGIVENESS (PSLF):
OMB No. 1845-0110
Form Approved
EMPLOYMENT CERTIFICATION FORM
Exp. Date 5/31/2020
William D. Ford Federal Direct Loan (Direct Loan) Program
PSECF - XBCR
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
PSLF ECF
the U.S. Criminal Code and 20 U.S.C. 1097.
SECTION 1: BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN
Date of Birth
Name
Address
City
State
Zip Code
Telephone - Primary
Telephone - Alternate
Email (Optional)
SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATION
Before signing, carefully read the entire form. For more information on 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 entity to which I submit this request and its agents to contact me regarding my request or my loans at any cellular
telephone number that I provide now or in the future 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 my Direct Loans while employed full-time by a qualifying
employer or employers. Neither the 120 qualifying payments nor the employment have to be consecutive.
2. To qualify for PSLF, I must be employed full-time by a qualifying employer when I apply for and receive PSLF.
3. If I qualify for forgiveness, only the remaining balance on my Direct Loans will be forgiven.
4. By submitting this form, my student loan(s) held by the Department will be transferred to FedLoan Servicing.
5. The Department may request supplemental documentation substantiating my employment.
6. The Department will notify me in writing or electronically of the number of qualifying payments I have made while
employed full-time by a qualifying employer and how many more I must make before I am eligible to apply for PSLF.
7. I will be notified if the form that I submit is incomplete, or if my employment or payments do not qualify for PSLF, why
the determination was made, and the steps I need to take to correct the form or make qualifying payments.
8.
The Department will retain this certification form until I submit my application for forgiveness.
I certify that all of the information I have provided on this form and in any accompanying document is true, complete, and
correct to the best of my knowledge and belief.
Check this box if you cannot obtain certification from your employer because the organization is closed or because the
organization has refused to certify your employment. The Department will follow up to assist you in getting
documentation of your employment. Complete Section 3, but do not complete Section 4.
Date
Borrower's Signature
Page 1 of 6
Borrower Name
Borrower SSN
SECTION 3: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
1. Employer Name:
10. Is your employer tax-exempt under Section 501(c)(3)
of the Internal Revenue Code (IRC)?
If your employer is tax-exempt under another
subsection of 501(c) of the IRC, such as 501(c)(4) or
2. Federal Employer Identification Number (FEIN)
501(c)(6), check "No" to this question.
Yes - Skip to Section 4.
Your employer's Federal EIN may be found on your
No - Continue to Item 11.
Wage and Tax Statement (W-2).
11. Is your employer a not-for-profit organization that is
3. Employer Address:
not tax-exempt under Section 501(c)(3) of the Internal
Revenue Code?
Yes - Continue to Item 12.
No - Your employer does not qualify.
4. Employer Website (if any):
12. Is your employer a partisan political organization or a
labor union?
Yes - Your employer does not qualify.
No - Continue to Item 13.
5. Employment Begin Date:
13. Which of the following services does your employer
provide as its primary purpose? Check all that apply
6. Employment End Date:
and then continue to Section 4. If you you check
"None of the above", do not submit this form.
Still Employed
OR
Emergency management
7. Employment Status:
Full-Time
Part-Time
Military service (See Section 6)
Public safety
8. Hours Per Week (Average)
Law enforcement
Include vacation, leave time, or any leave taken
Public interest legal services (See Section 6)
under the Family Medical Leave Act of 1993. If your
employer is a 501(c)(3) or a not-for-profit organization,
Early childhood education (See Section 6)
do not include any hours you spent on religious
Public service for individuals with disabilities
instruction, worship services, or proselytizing.
Public service for the elderly
9. Is your employer a governmental organization?
Public health (See Section 6)
A governmental organization is a Federal, State,
Public education (See Section 6)
local, or Tribal government organization, agency, or
Public library services
entity, a public child or family service agency, a Tribal
college or university, or the Peace Corps or
School library services
AmeriCorps.
Other school-based services
Yes - Skip to Section 4.
None of the above - the employer does not
No - Continue to Item 10.
qualify.
SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)
By signing, I certify (1) that the information in Section 3 is true, complete, and correct to the best of my knowledge and
belief, (2) that I am an authorized official (see Section 6) of the organization named in Section 3, and (3) that the borrower
named in Section 1 is or was an employee of the organization named in Section 3.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
Official's Name
Official's Phone
Official's Title
Official's Email
Date
Authorized Official's Signature
Page 2 of 6
SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM
If you have made 120 qualifying payments and the certification in Sections 3 and 4 does not cover all of those payments, you
must provide information about other employers by submitting one copy of Sections 1 and 2 (Page 1), and one copy of
Sections 3 and 4 (Page 2) per employer. When completing this form, type or print using dark ink. Enter dates as month-day-
year (mm-dd-yyyy). Use only numbers. Example: March 14, 2016 = 03-14-2016. 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 7.
SECTION 6: DEFINITIONS
QUALIFYING PAYMENT DEFINITIONS
QUALIFYING EMPLOYMENT DEFINITIONS (CONTINUED)
Qualifying payments are separate, on-time, full monthly
An employee means an individual who is hired and paid
payments made on an eligible loan after October 1, 2007
by the qualifying employer.
Full-time means working for one or more qualifying
under a qualifying repayment plan while employed full-time
employers for the greater of: (1) An annual average of at
by a qualifying employer.
An on-time payment is a payment made no more than
least 30 hours per week or, for a contractual or employment
period of at least 8 months, an average of 30 hours per
15 days after the due date for the payment.
Eligible loans are loans made under the William D. Ford
week; or (2) Unless the qualifying employment is with two
Federal Direct Loan (Direct Loan) Program that are not in
or more employers, the number of hours the employer
considers full time.
default.
Qualifying repayment plans include the Revised Pay As
An authorized official is an official of a qualifying
You Earn (REPAYE) plan, the Pay As You Earn (PAYE) plan,
employer who has access to the borrower's employment or
service records and is authorized by the employer to certify
the Income-Based Repayment (IBR) plan, the Income-
Contingent Repayment (ICR) plan, the Standard Repayment
the employment status of the organization's employees or
plan with a maximum 10-year repayment period, and any
former employees, or the service of AmeriCorps or Peace
Corps volunteers.
other Direct Loan repayment plan if payments are at least
Early childhood education includes licensed or
equal to the monthly payment amount that would be
required under the Standard Repayment plan with a 10-year
regulated child care, Head Start, and State funded pre-
kindergarten.
repayment period.
Law enforcement means crime prevention, control or
QUALIFYING EMPLOYMENT DEFINITIONS
reduction of crime, or the enforcement of criminal law.
A Qualifying employer includes the government, a not-
Military service means service on behalf of the U. S.
for-profit organization that is tax-exempt under Section
Armed Forces or the National Guard.
501(c)(3) of the Internal Revenue Code, or a private not-for-
Public education includes services that provide
profit organization that provides certain public services.
educational enrichment or support directly to students or
Serving in an AmeriCorps or Peace Corps position is also
their families in a school or a school-like setting.
qualifying employment.
Public interest legal services refers to legal services
Government includes a Federal, State, local or Tribal
that are funded in whole or in part by a local, State, Federal,
government organization, agency or entity; a public child or
or Tribal government.
family service agency; or a Tribal college or university.
Public health includes nurses, nurse practitioners,
A private not-for-profit organization is an
nurses in a clinical setting, and full-time professionals
organization that is not organized for profit, is not a labor
engaged in
health care practitioner occupations
and
health
union, is not a partisan political organization, and provides
support
occupations, as such terms are defined by the
at least one of the following public services as its primary
Bureau of Labor Statistics.
purpose: (1) emergency management, (2) military service,
(3) public safety, (4) law enforcement, (5) public interest
OTHER DEFINITIONS
legal services, (6) early childhood education, (7) public
A forbearance is a period during which you are allowed
service for individuals with disabilities and the elderly, (8)
to postpone making payments temporarily, allowed an
public health, (9) public education, (10) public library
extension of time for making payments, or temporarily
services, (11) school library services, or (12) other school-
allowed to make smaller payments than scheduled. A
based services.
forbearance can be a mandatory forbearance, meaning that
AmeriCorps position means a position approved by the
your loan holder must grant the forbearance if you qualify
Corporation for National and Community Service under
for the forbearance and supply all supporting
Section 123 of the National and Community Service Act of
documentation. A forbearance can also be a discretionary
1990 (42 U.S.C. 12573).
forbearance, meaning that your loan holder may grant the
Peace Corps position means a full-time assignment
forbearance, but is not required to do so.
under the Peace Corps Act as provided for under 22 U.S.C.
2504.
Page 3 of 6
SECTION 7: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to:
If you need help completing this form, call:
Mail to: U.S. Department of Education, FedLoan Servicing,
Domestic: 855-265-4038.
P.O. Box 69184, Harrisburg, PA 17106-9184.
International: 717-720-1985.
TTY: dial 711, then enter 800-699-2908.
Fax to: 717-720-1628.
Website:
MyFedLoan.org.
Upload to: MyFedLoan.org/FileUpload, if FedLoan
Servicing is already your servicer.
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF
You may receive loan forgiveness under this program only
PAYMENT ELIGIBILITY (CONTINUED)
after you have made 120 qualifying payments (see
If you make a lump sum payment by using an
"Payment Eligibility") on eligible loans (see "Loan Eligibility"
AmeriCorps Segal Education Award or a Peace Corps
on page 5) while working full-time in qualifying
transition payment, or if a lump sum payment is made on
employment (see "Employment Eligibility" on page 5).
your behalf through a DOD student loan repayment
program, the Department will give you credit for qualifying
PAYMENT ELIGIBILITY
payments equal to the lesser of (1) the number of payments
To receive PSLF, you must make 120 on-time, full,
resulting after dividing the amount of the lump sum
scheduled, separate monthly payments on your Direct Loans
payment by the monthly payment amount you would have
under a qualifying repayment plan after October 1, 2007.
made under one of the qualifying repayment plans listed
On-time payments are those that are received by your
below; or (2) 12 payments.
servicer no later than 15 days after the scheduled payment
If you make an eligible lump sum payment using a Peace
due date.
Corps transition payment, you must do so within 6 months
Full payments are payments on your Direct Loan in an
of the Employment End Date, as reported in Section 3.
amount that equals or exceeds the amount you are required
You may only use an AmeriCorps Segal Education Award
to pay each month under your repayment schedule. If you
or Peace Corps transition payment one time to receive
make a payment that is less than what you are required to
credit for more than one qualifying payment towards PSLF.
pay for that month, that month's payment will not count as
However, lump sum payments made on your behalf under a
one of the required 120 qualifying payments. If you make
DOD student loan repayment program may be counted as
multiple, partial payments in a month and the total of those
up to 12 qualifying payments for each year that a lump sum
partial payments equals or exceeds the required full
payment is made.
monthly payment amount, those payments will count as
Your payments must be made under a qualifying
one qualifying payment.
repayment plan. Qualifying repayment plans include the
Scheduled payments are those that are made while you
REPAYE plan, the PAYE plan, the IBR plan, the ICR plan, the
are in repayment. They do not include payments made while
10-Year Standard Repayment plan, or any other Direct Loan
your loans are in an in-school or grace status, or in a
repayment plan, but only payments that are at least equal to
deferment or forbearance period.
the monthly payment amount that would be required under
You must make separate monthly payments. Except as
the10-Year Standard Repayment plan.
explained below, lump sum payments or payments you
Though repayment plans other than the REPAYE, PAYE,
make as advance payments for future months do not count
IBR, and ICR plans are qualifying repayment plans for PSLF,
as more than one qualifying payment. If you want to pay
you must enter REPAYE, PAYE, IBR, or ICR to have a
more than your scheduled monthly payment amount, follow
remaining balance to forgive after becoming eligible for
the instructions on your bill to let your servicer know that
PSLF. Otherwise, your loans will be fully repaid within 10
your payment is not intended to cover future installments.
years. To apply for these plans, visit StudentLoans.gov.
Otherwise, you may not receive credit for future qualifying
IMPORTANT: The Standard Repayment Plan for Direct
payments.
Consolidation Loans made on or after July 1, 2006 has
If you were an AmeriCorps or Peace Corps volunteer, you
repayment periods that range from 10 to 30 years. Monthly
may receive credit for making qualifying payments if you
payments you make under this plan are qualifying payments
make a lump sum payment by using all or part of a Segal
only if the repayment period is 10 years, which would be the
Education Award or Peace Corps transition payment.
case only if the total amount of the consolidation loan and
You may also receive credit for qualifying payments if a
your other eligible student loans is less than $7,500.
lump sum payment is made on your behalf through a
student loan repayment program administered by the U.S.
Department of Defense (DOD).
Page 4 of 6
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)
LOAN ELIGIBILITY
EMPLOYMENT ELIGIBILITY (CONTINUED)
Only Direct Loan Program loans that are not in default
A private not-for-profit organization that is not a tax-
are eligible for PSLF. Loans you received under the Federal
exempt organization under Section 501(c)(3) of the IRC may
Family Education Loan (FFEL) Program, the Federal Perkins
be a qualifying organization if it provides certain specified
Loan (Perkins Loan) Program, or any other student loan
public services. These services include emergency
program are not eligible for PSLF.
management, military service, public safety, or law
enforcement services; public health services; public
If you have FFEL Program or Perkins Loan Program loans,
education or public library services; school library and other
you may consolidate them into a Direct Consolidation Loan
school-based services; public interest legal services; early
to take advantage of PSLF. However, payments made on
childhood education; public service for individuals with
your FFEL Program or Perkins Loan Program loans before
disabilities and the elderly. The organization must not be a
you consolidated them, even if they were made under a
business organized for profit, a labor union, or a partisan
qualifying repayment plan, do not count as qualifying PSLF
political organization.
payments. In addition, if you made qualifying payments on a
Direct Loan and then consolidate it into a Direct
Employment as a member of the U.S. Congress is not
Consolidation Loan, you must start over making qualifying
qualifying employment.
payments on the new Direct Consolidation Loan.
You must be employed full-time by your employer.
If you are planning to consolidate your FFEL Program or
Generally, you must meet your employer's definition of
Perkins Loan Program loans into a Direct Consolidation Loan
full-time. However, for PSLF purposes, that definition must
to take advantage of PSLF and do not have any Direct Loans,
be at least an annual average of 30 hours per week. For
do not submit this form until you have consolidated your
purposes of the full-time requirement, your qualifying
loans. The online application for Direct Consolidation Loans
employment at a 501(c)(3) organization or a not-for-profit
contains a section that allows you to indicate that you are
organization does not include time spent participating in
consolidating your loans for PSLF. If you plan to consolidate
religious instruction, worship services, or any form of
Perkins Loan Program loans, first understand that Perkins
proselytizing.
Loan Program loans may be cancelled for certain types of
If you are a teacher or in another position under contract
public service. If you consolidate a Perkins Loan Program
for at least eight out of 12 months, you meet the full-time
loan, you will no longer be eligible for Perkins cancellation.
standard if you work an average of at least 30 hours per
The online application is available at StudentLoans.gov. If
week during the contractual period and receive credit by
you don't know whether you have Direct Loans, go to
your employer for a full year's worth of employment.
StudentAid.gov/login.
If you are employed in more than one qualifying part-
EMPLOYMENT ELIGIBILITY
time job simultaneously, you may meet the full-time
To qualify for PSLF, you must be an employee of a
employment requirement if you work a combined average
qualifying employer. An employee is someone who is hired
of at least 30 hours per week with your employers.
and paid by the employer. You may physically perform your
Vacation or leave time provided by the employer or leave
work at a qualifying or non-qualifying organization, as long
taken for a condition that is a qualifying reason for leave
as you are an employee of a qualifying employer. If you are
under the Family and Medical Leave Act of 1993, 29, U.S.C.
working at the location of or with an organization under
2612(a)(1) and (3) is equivalent to hours worked in qualifying
contract with your employer, the organization that hired
employment.
and pays you must be a qualifying employer, not the
organization where you perform your work.
OTHER IMPORTANT INFORMATION
A qualifying organization is a government organization, a
If you submit this form and your employer qualifies, all of
tax-exempt organization under Section 501(c)(3) of the
your loans held by the Department will be transferred to
Internal Revenue Code, or a private not-for-profit
FedLoan Servicing. FedLoan Servicing will then determine
organization that provides certain public services. Service in
how many qualifying payments you made during the period
an AmeriCorps or Peace Corps position is also qualifying
of qualifying employment within the dates provided in
employment.
Section 3.
You are not permitted to apply the same period of
service to receive PSLF and the Teacher Loan Forgiveness
and Civil Legal Assistance Attorney Student Loan
Repayment programs.
Page 5 of 6