PUBLIC SERVICE LOAN FORGIVENESS (PSLF): OMB No.

1845-0110
Form Approved
EMPLOYMENT CERTIFICATION FORM Exp. Date 12/31/2017
William D. Ford Federal Direct Loan (Direct Loan) Program Records Code: PSECF-XBCR
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on
PSLF ECF 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 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 CERTIFICATIONS
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 Loan(s) 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 Loan(s) 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. 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.
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.

Borrower's Signature Date

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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?
Yes - Skip to Section 4.
2. Federal Employer Identification Number (FEIN) No - Continue to Item 11.

11. Is your employer a not-for-profit organization?

Your employer's EIN may be found on your Wage Yes - Continue to Item 12.
and Tax Statement (W-2). No - Your employer does not qualify.
3. Employer Address: 12. Is your employer a partisan political organization?
Yes - Your employer does not qualify.

4. Employer Website (if any): No - Continue to Item 13.

13. Is your employer a labor union?

Yes - Your employer does not qualify.
5. Employment Begin Date:
No - Continue to Item 14.
14. Indicate which service or services your employer
6. Employment End Date: provides and then continue to Section 4, if
appropriate:
OR Emergency management
Still Employed Military service (See Section 6)
7. Employment Status: Full-Time Part-Time Public safety
Law enforcement
8. Hours Per Week (Average)
Public interest legal services (See Section 6)
Include vacation, leave time, or any leave taken
under the Family Medical Leave Act of 1993. If your Early childhood education (See Section 6)
employer is a 501(c)(3) or a not-for-profit organization, Public service for individuals with disabilities
do not include any hours you spent on religious
instruction, worship services, or proselytizing. Public service for the elderly
Public health (See Section 6)
9. Is your employer a governmental organization?
Public education (See Section 6)
A governmental organization is a Federal, State,
Public library services
local, or Tribal government organization, agency, or
entity, a public child or family service agency, a Tribal School library services
college or university, or the Peace Corps or Other school-based services
AmeriCorps.
Yes - Skip to Section 4. None of the above - your employer does not
qualify.
No - Continue to Item 10.

SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)

By signing, I certify that the information in Section 3 is true, complete, and correct to the best of my knowledge and belief
and that I am an authorized official (see Section 6) of the organization named in Section 3. Complete the rest of this Section.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
Authorized Official's Name Authorized Official's Phone
Authorized Official's Title Authorized Official's Email

Authorized Official's Signature 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 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. 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
StudentAid.gov/publicservice. Return the completed form to the address shown in Section 7.
SECTION 6: DEFINITIONS
AmeriCorps position means a position approved by the Peace Corps position means a full-time assignment
Corporation for National and Community Service under under the Peace Corps Act as provided for under 22 U.S.C.
Section 123 of the National and Community Service Act of 2504.
1990 (42 U.S.C. 12573). Public education includes services that provide
An authorized official is an official of a public service educational enrichment or support directly to students or
organization (including AmeriCorps or the Peace Corps) their families in a school or a school-like setting.
who has access to the borrower's employment or service Public interest legal services refers to legal services
records and is authorized by the public service organization that are funded in whole or in part by a local, State, Federal,
to certify the employment status of the organization's or Tribal government.
employees or former employees, or the service of Public health includes nurses, nurse practitioners,
AmeriCorps or Peace Corps volunteers. nurses in a clinical setting, and full-time professionals
Eligible loans are loans that are not in default and made engaged in health care practitioner occupations and health
under the William D. Ford Federal Direct Loan (Direct Loan) support occupations, as such terms are defined by the
Program. Bureau of Labor Statistics.
Early childhood education includes licensed or A public service organization is a private not-for-profit
regulated child care, Head Start, and State funded pre- organization that is not a labor union or a partisan political
kindergarten. organization and that provides at least one of the following
An employee means an individual who is hired and paid public services: (1) emergency management, (2) military
by the organization. service, (3) public safety, (4) law enforcement, (5) public
Full-time means working in qualifying employment in interest legal services, (6) early childhood education, (7)
one or more jobs for the greater of: (1) An annual average of public service for individuals with disabilities and the
at least 30 hours per week or, for a contractual or elderly, (8) public health, (9) public education, (10) public
employment period of at least 8 months, an average of 30 library services, (11) school library services, or (12) other
hours per week; or (2) Unless the qualifying employment is school-based services.
with two or more employers, the number of hours the Qualifying payments are separate, on-time, full monthly
employer considers full time. payments made on a Direct Loan after October 1, 2007
Government includes a Federal, State, local or Tribal under a qualifying repayment plan.
government organization, agency or entity; a public child or Qualifying employment includes employment by the
family service agency; or a Tribal college or university. government, employment by a not-for-profit organization
An on-time payment is a payment made no more than that is tax-exempt under Section 501(c)(3) of the Internal
15 days after the due date for the payment. Revenue Code, AmeriCorps position, a Peace Corps position,
Law enforcement means service performed by an or employment at a public service organization.
employee of a public service organization that is publicly Qualifying repayment plans include the Revised Pay As
funded and whose principal activities pertain to crime You Earn (REPAYE) plan, the Pay As You Earn (PAYE) plan,
prevention, control or reduction of crime, or the the Income-Based Repayment (IBR) plan, the Income-
enforcement of criminal law. Contingent Repayment (ICR) plan, the 10-Year Standard
Military service means service on behalf of the U. S. Repayment plsn (Standard Repayment plan with a
Armed Forces or the National Guard performed by an maximum 10-year repayment period), and any other Direct
employee of a public service organization. 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: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to: If you need help completing this form, call:
(If no address is shown, return to your loan holder.) (If no telephone number is shown, call your loan holder.)

U.S. Department of Education Domestic: 855-265-4038

FedLoan Servicing Or Fax to: 717-720-1628 International: 717-720-1985
P.O. Box 69184 TTY: dial 711, then enter 800-699-2908
Harrisburg, PA 17106-9184
Website: MyFedLoan.org
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF
You may obtain loan forgiveness under this program if you The Department will consider the lump sum payment
make 120 qualifying payments (see "Payment Eligibility") on you have made as the equivalent of qualifying payments
eligible loans (see "Loan Eligibility") while working in equal to the lesser of (1) the number of payments resulting
qualifying employment (see "Employment Eligibility"). after dividing the amount of the lump sum payment by the
Payment Eligibility monthly payment amount you would have made under one
of the qualifying repayment plans listed below; or (2) 12
To receive PSLF, you must make 120 on-time, full,
payments.
scheduled, separate monthly payments on your Direct Loans
under a qualifying repayment plan after October 1, 2007. Peace Corps volunteers making an eligible lump sum
payment must do so within 6 months of the Employment
On-time payments are those that are received by the
End Date, as reported in Section 3.
Department no later than 15 days after the scheduled
payment due date. Your payments must be made under a qualifying
repayment plan. Qualifying repayment plans include the
Full payments are payments on your Direct Loan in an
REPAYE plan, the PAYE plan, the IBR plan, the ICR plan, the
amount that equals or exceeds the amount you are required
10-Year Standard Repayment plan, or any other Direct Loan
to pay each month under your repayment schedule. If you
repayment plan, but only payments that are at least equal to
make a payment that is less than what you are required to
the monthly payment amount that would be required under
pay for that month, that month's payment will not count as
the10-Year Standard Repayment plan.
one of the required 120 qualifying payments. If you make
multiple, partial payments in a month and the total of those Though repayment plans other than the REPAYE, PAYE,
partial payments equals or exceeds the required full IBR, and ICR plans are qualifying repayment plans for PSLF,
monthly payment amount, those payments will count as you must enter REPAYE, PAYE, IBR, or ICR to have a
one qualifying payment. remaining balance to forgive after becoming eligible for
PSLF. Otherwise, your loans will be fully repaid within 10
Scheduled payments are those that are made while you
years. To apply for these plans, visit StudentLoans.gov.
are in repayment. They do not include payments made while
your loans are in an in-school or grace status, or in a IMPORTANT: The Standard Repayment Plan for Direct
deferment or forbearance period. Consolidation Loans made on or after July 1, 2006 have
repayment periods of different lengths. Monthly payments
You must make separate monthly payments. Lump sum
you make under the Standard Repayment Plan on such
payments or payments you make as advance payments for
Direct Consolidation Loans are only qualifying payments if
future months do not count as more than one qualifying
the loans have a 10-year repayment period (which would
payment. If you wish to make a payment in excess of your
only occur if your total education indebtedness is less than
scheduled monthly payment, follow the instructions on your
$7,500).
bill for providing payment instructions, and notate that your
payment is not intended to cover future installments. Loan Eligibility
Otherwise, your excess payment may affect your ability to
Only Direct Loan Program loans that are not in default
make future qualifying payments.
are eligible for PSLF. Loans you received under the Federal
If you were an AmeriCorps or Peace Corps volunteer, you Family Education Loan (FFEL) Program, the Federal Perkins
may receive credit for making qualifying payments if you Loan (Perkins Loan) Program, or any other student loan
make a lump sum payment by using all or part of a Segal program are not eligible for PSLF.
Education Award or Peace Corps transition payment.

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SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)
Loan Eligibility (Continued) Employment Eligibility (Continued)
If you have FFEL Program or Perkins Loan Program loans, You must be employed full-time by your employer.
you may consolidate them into a Direct Consolidation Loan
Generally, you must meet your employer's definition of
to take advantage of PSLF. However, payments made on
full-time. However, for PSLF purposes, that definition must
your FFEL Program or Perkins Loan Program loans before
be at least an annual average of 30 hours per week. For
you consolidated them, even if they were made under a
purposes of the full-time requirement, your qualifying
qualifying repayment plan, do not count as qualifying PSLF
employment at a 501(c)(3) organization or a not-for-profit
payments. In addition, if you made qualifying payments on a
organization does not include time spent participating in
Direct Loan and then consolidate it into a Direct
religious instruction, worship services, or any form of
Consolidation Loan, you must start over making qualifying
proselytizing.
payments on the new Direct Consolidation Loan.
If you are a teacher, or other employee of a public service
If you consolidate your FFEL Program or Perkins Loan
organization, under contract for at least eight out of 12
Program loans into a Direct Consolidation Loan to take
months, you meet the full-time standard if you work an
advantage of PSLF and do not have any Direct Loans, do not
average of at least 30 hours per week during the contractual
submit this form until you have consolidated your loans. The
period and receive credit by your employer for a full year's
online application for Direct Consolidation Loans contains a
worth of employment.
section that allows you to indicate that you are
consolidating your loans for PSLF. The online application is If you are employed in more than one qualifying part-
available at StudentLoans.gov. If you don't know whether time job simultaneously, you may meet the full-time
you have Direct Loans, go to StudentAid.gov/login. employment requirement if you work a combined average
of at least 30 hours per week with your employers.
Employment Eligibility Vacation or leave time provided by the employer or leave
To qualify for PSLF, you must be an employee of a taken for a condition that is a qualifying reason for leave
qualifying organization. An employee is someone who is under the Family and Medical Leave Act of 1993, 29, U.S.C.
hired and paid by the organization. You may physically 2612(a)(1) and (3) is equivalent to hours worked in qualifying
perform your work at a qualifying or non-qualifying employment.
organization, so long as your employer is a qualifying
organization. If you are a contracted employee, the Other Important Information
organization that hired and pays you must qualify, not the The submission of this form before you apply for PSLF is
organization where you perform your work. The type or optional. However, if you wait to submit this form until you
nature of employment with the organization does not apply for PSLF, you will be required to submit one form for
matter for PSLF purposes. each employer that you want considered toward your
eligibility for PSLF.
A qualifying organization is a government organization
or a tax-exempt organization under Section 501(c)(3) of the If you submit this form and your employer qualifies, all of
Internal Revenue Code (IRC). Service in an AmeriCorps or your loans held by the Department will be transferred to
Peace Corps position is also qualifying employment. The FedLoan Servicing. FedLoan Servicing will then determine
type of services that these organizations provide does not how many qualifying payments you made during the period
matter for PSLF purposes. of qualifying employment within the dates provided in
Section 3.
A private not-for-profit organization that is not a tax-
exempt organization under Section 501(c)(3) of the IRC may You are not permitted to apply the same period of
be a qualifying organization if it provides certain specified service to receive PSLF and the Teacher Loan Forgiveness,
public services. These services include emergency Service in Areas of National Need, and Civil Legal Assistance
management, military service, public safety, or law Attorney Student Loan Repayment programs.
enforcement services; public health services; public No borrower will be eligible for PSLF until October 2017
education or public library services; school library and other at the earliest. An application for PSLF will be made available
school-based services; public interest law services; early at a later time.
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.

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SECTION 9: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. To assist program administrators with tracking
552a) requires that the following notice be provided to you: refunds and cancellations, disclosures may be made to
The authorities for collecting the requested guaranty agencies, to financial and educational institutions,
information from and about you are 421 et seq., 451 et or to federal or state agencies. To provide a standardized
seq., or 461 of the Higher Education Act of 1965, as method for educational institutions to efficiently submit
amended (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., or student enrollment statuses, disclosures may be made to
20 U.S.C. 1087aa et seq.) and the authorities for collecting guaranty agencies or to financial and educational
and using your Social Security Number (SSN) are 428B(f) institutions. To counsel you in repayment efforts, disclosures
and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) may be made to guaranty agencies, to financial and
and 31 U.S.C. 7701(b). Participating in the William D. Ford educational institutions, or to federal, state, or local
Federal Direct Loan (Direct Loan) Program, Federal Family agencies.
Education Loan (FFEL) Program, or Federal Perkins Loan In the event of litigation, we may send records to the
(Perkins Loan) Program and giving us your SSN are Department of Justice, a court, adjudicative body, counsel,
voluntary, but you must provide the requested information, party, or witness if the disclosure is relevant and necessary
including your SSN, to participate. to the litigation. If this information, either alone or with
The principal purposes for collecting the other information, indicates a potential violation of law, we
information on this form, including your SSN, are to verify may send it to the appropriate authority for action. We may
your identity, to determine your eligibility to receive a loan send information to members of Congress if you ask them
or a benefit on a loan (such as a deferment, forbearance, to help you with federal student aid questions. In
discharge, or forgiveness) under the Direct Loan, FFEL, or circumstances involving employment complaints,
Federal Perkins Loan Programs, to permit the servicing of grievances, or disciplinary actions, we may disclose relevant
your loans, and, if it becomes necessary, to locate you and records to adjudicate or investigate the issues. If provided
to collect and report on your loans if your loans become for by a collective bargaining agreement, we may disclose
delinquent or default. We also use your SSN as an account records to a labor organization recognized under 5 U.S.C.
identifier and to permit you to access your account Chapter 71. Disclosures may be made to our contractors for
information electronically. the purpose of performing any programmatic function that
requires disclosure of records. Before making any such
The information in your file may be disclosed, on a disclosure, we will require the contractor to maintain Privacy
case-by-case basis or under a computer matching program, Act safeguards. Disclosures may also be made to qualified
to third parties as authorized under routine uses in the researchers under Privacy Act safeguards.
appropriate systems of records notices. The routine uses of Paperwork Reduction Notice. According to the
this information include, but are not limited to, its disclosure Paperwork Reduction Act of 1995, no persons are required
to federal, state, or local agencies, to private parties such as to respond to a collection of information unless such
relatives, present and former employers, business and collection displays a valid OMB control number. The valid
personal associates, to consumer reporting agencies, to OMB control number for this information collection is
financial and educational institutions, and to guaranty 1845-0110. Public reporting burden for this collection of
agencies in order to verify your identity, to determine your information is estimated to average 30 minutes per
eligibility to receive a loan or a benefit on a loan, to permit response, including time for reviewing instructions,
the servicing or collection of your loans, to enforce the searching existing data sources, gathering and maintaining
terms of the loans, to investigate possible fraud and to verify the data needed, and completing and reviewing the
compliance with federal student financial aid program collection of information. The obligation to respond to this
regulations, or to locate you if you become delinquent in collection is required to obtain a benefit in accordance with
your loan payments or if you default. To provide default rate 34 CFR 685.219. If you have comments or concerns
calculations, disclosures may be made to guaranty agencies, regarding the status of your individual submission of this
to financial and educational institutions, or to state form, please contact your loan holder directly (see Section
agencies. To provide financial aid history information, 7).
disclosures may be made to educational institutions.

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