Public Service Loan Forgiveness Employment Certification Form - Free Download
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PUBLIC SERVICE LOAN FORGIVENESS (PSLF):
EMPLOYMENT CERTIFICATION FORM
William D. Ford Federal Direct Loan (Direct Loan) Program
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.
OMB No. 1845-0110
Exp. Date 12/31/2017
SECTION 1: BORROWER INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
City State Zip Code
Telephone - Primary
Telephone - Alternate
Date of Birth
SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS
Before signing, carefully read the entire form. For more information on PSLF, visit StudentAid.gov/publicservice
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.
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