1 PUBLIC SERVICE LOAN FORGIVENESS (PSLF): EMPLOYMENT CERTIFICATION FORM OMB N Frm Apprved Exp. Date 12/31/2017 William D. Frd Federal Direct Lan (Direct Lan) Prgram WARNING: Any persn wh knwingly makes a false statement r misrepresentatin n this frm r n any accmpanying dcument is subject t penalties that may include fines, imprisnment, r bth, under the U. S. Criminal Cde and 20 U. S. C SECTION 1: BORROWER IDENTIFICATION Please enter r crrect the fllwing infrmatin. Check this bx if any f yur infrmatin has changed. SSN Date f Birth Name Frmer Name (if any) Address City, State, Zip Telephne Primary Telephne Alternate (ptinal) SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS , ( ) - ( ) - Befre signing, carefully read the entire frm. Fr mre infrmatin abut PSLF, visit StudentAid.gv/publicservice. I authrize: 1. My emplyer r ther entity having recrds abut the emplyment that is the basis f my request t make infrmatin frm thse recrds available t the U. S. Department f Educatin (the Department) r its agents r cntractrs. 2. The Department (and its agents r cntractrs) t cntact me regarding my request r my lan(s), including repayment f my lan(s), at the telephne number that I prvide n this frm r any future number that I prvide fr my cellular telephne r ther wireless device using autmated telephne dialing equipment r artificial r prerecrded vice r text messages. I understand that: 1. T qualify fr PSLF, I must make 120 qualifying payments n my Direct Lan(s) while emplyed full-time by a qualifying emplyer r emplyers. Neither the 120 qualifying payments nr emplyment have t be cnsecutive. 2. T qualify fr PSLF, I must be emplyed full-time by a qualifying emplyer r emplyers when I apply fr PSLF and when my lan is frgiven. 3. If I qualify fr frgiveness, nly the remaining balance n my Direct Lan(s) will be frgiven. 4. By submitting this frm, my student lan(s) held by the Department will be transferred t FedLan Servicing. 5. The Department may request supplemental dcumentatin substantiating my emplyment. 6. The Department will ntify me in writing r electrnically f the number f qualifying payments I have made while emplyed full-time by a qualifying emplyer r emplyers and the remaining number f qualifying payments I must make befre I am eligible t apply fr PSLF. 7. The Department will ntify me in writing r electrnically if the frm that I submit is incmplete, r if it determines that my emplyment r payments d nt qualify fr PSLF. The Department will explain the reasn fr the determinatin and the steps I need t take t crrect the frm r make qualifying payments. 8. The Department will retain this certificatin frm until I submit my applicatin fr frgiveness. I certify that all f the infrmatin I have prvided n this frm and in any accmpanying dcument is true, cmplete, and crrect t the best f my knwledge and belief. Check this bx if yu cannt btain certificatin frm yur emplyer because the rganizatin is clsed r because the rganizatin has refused t certify yur emplyment. The Department will fllw up t assist yu in getting dcumentatin f yur emplyment. Cmplete Sectin 3, but d nt cmplete Sectin 4. Brrwer Signature Date - - Page 1 f 6
2 Brrwer Name: Brrwer SSN: - - SECTION 3: EMPLOYMENT INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER) 1. Emplyer Name: 2. Federal Emplyer Identificatin Number (EIN): - Yur emplyer s EIN may be fund n yur Wage and Tax Statement (W-2). 3. Emplyer Address: 4. Emplyer Website (if any) 5. Emplyment Begin Date: Emplyment End Date: - - OR Still emplyed. 7. Emplyment Status: Full-Time Part-Time 8. Hurs Per Week (Average): Include vacatin, leave time, r any leave taken under the Family Medical Leave Act f If yur emplyer is a 501(c)(3) r a nt-fr-prfit rganizatin, d nt include any hurs yu spent n religius instructin, wrship services, r prselytizing. 9. Is yur emplyer a gvernmental rganizatin? A gvernmental rganizatin is a Federal, State, lcal, r Tribal gvernment rganizatin, agency, r entity, a public child r family service agency, a Tribal cllege r university, r the Peace Crps r AmeriCrps. Yes Skip t Sectin 4. N Cntinue t Item 10. SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER) 10. Is yur emplyer a tax-exempt rganizatin under sectin 501(c)(3) f the Internal Revenue Cde? Yes Skip t Sectin 4 N Cntinue t Item Is yur emplyer a nt-fr-prfit rganizatin? Yes Cntinue t Item 12. N Yur emplyer des nt qualify. 12. Is yur emplyer a partisan plitical rganizatin? Yes Yur emplyer des nt qualify. N Cntinue t Item Is yur emplyer a labr unin? Yes Yur emplyer des nt qualify. N Cntinue t Item Des yur emplyer prvide any f the belw services? Yes Select all the services yur emplyer prvides and then cntinue t Sectin 4. Emergency management Military service (see Sectin 6) Public safety Law enfrcement (see Sectin 6) Public interest legal services (see Sectin 6) Early childhd educatin (see definitin f public service rganizatin in Sectin 6) Public service fr individuals with disabilities Public service fr the elderly Public health (see definitin f public service rganizatin in Sectin 6) Public educatin Public library services Schl library services Other schl-based services N Yur emplyer des nt qualify. 15. I certify that the infrmatin in Sectin 3 is true, cmplete, and crrect t the best f my knwledge and belief and that I am an authrized fficial (see Sectin 6) f the rganizatin named in Sectin 3. Cmplete Items Nte: If any f the infrmatin is crssed ut r altered in Sectin 3, yu must initial thse changes. 16. Authrized Official s Name: 19. Authrized Official s Phne: 17. Authrized Official s Title: 18. Authrized Official s Signature: Page 2 f 6 ( ) Authrized Official s Date: - -
3 SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM Yu may submit infrmatin abut multiple emplyers by submitting ne cpy f Sectins 1 and 2 (Page 1), and ne cpy f Sectins 3 and 4 (Page 2) per emplyer. When cmpleting this frm, type r print using dark ink. Enter dates as mnth-day-year (mm-dd-yyyy). Use nly numbers. Example: March 14, 2014 = If any infrmatin is crssed ut r altered in Sectin 3, it must be initialed by yur emplyer. Fr mre infrmatin abut PSLF and hw t use this frm, visit StudentAid.gv/publicservice. Return the cmpleted frm t the address shwn in Sectin 7. SECTION 6: DEFINITIONS AmeriCrps psitin means a psitin apprved by the Crpratin fr Natinal and Cmmunity Service under Sectin 123 f the Natinal and Cmmunity Service Act f 1990 (42 U.S.C ). An authrized fficial is an fficial f a public service rganizatin (including AmeriCrps r the Peace Crps) wh has access t the brrwer s emplyment r service recrds and is authrized by the public service rganizatin t certify the emplyment status f the rganizatin s emplyees r frmer emplyees, r the service f AmeriCrps r Peace Crps vlunteers. Eligible lans are lans that are nt in default and made under the William D. Frd Federal Direct Lan (Direct Lan) Prgram. An emplyee means an individual wh is hired and paid by a public service rganizatin. Full-time means wrking in qualifying emplyment in ne r mre jbs fr the greater f: An annual average f at least 30 hurs per week r, fr a cntractual r emplyment perid f at least 8 mnths, an average f 30 hurs per week; r Unless the qualifying emplyment is with tw r mre emplyers, the number f hurs the emplyer cnsiders full time. An n-time payment is a payment made n mre than 15 days after the due date fr the payment. Law enfrcement means service perfrmed by an emplyee f a public service rganizatin that is publicly funded and whse principal activities pertain t crime preventin, cntrl r reductin f crime, r the enfrcement f criminal law. Military service fr unifrmed members f the U.S. Armed Frces r the Natinal Guard means active duty service r full-time Natinal Guard duty as defined in Sectin 101(d)(1) and (d)(5) f Title 10 f the United States Cde, but des nt include active duty fr training r attendance at a service schl. Fr civilians, military service means service n behalf f the U. S. Armed Frces r the Natinal Guard perfrmed by an emplyee f a public service rganizatin. Peace Crps psitin means a full-time assignment under the Peace Crps Act as prvided fr under 22 U.S.C Public interest law refers t legal services prvided by a public service rganizatin that are funded in whle r in part by a lcal, State, Federal, r Tribal gvernment. A public service rganizatin is: A Federal, State, lcal r Tribal gvernment rganizatin, agency r entity; A public child r family service agency; A nn-prfit rganizatin under Sectin 501(c)(3) f the Internal Revenue Cde that is exempt frm taxatin under Sectin 501(a) f the Internal Revenue Cde; A Tribal cllege r university; r A private rganizatin (that is nt a business rganized fr prfit, a labr unin, r a partisan plitical rganizatin) that prvides at least ne f the fllwing public services: (1) emergency management, (2) military service, (3) public safety, (4) law enfrcement, (5) public interest law services, (6) early childhd educatin (including licensed r regulated child care, Head Start, and State funded pre-kindergarten), (7) public service fr individuals with disabilities and the elderly, (8) public health (including nurses, nurse practitiners, nurses in a clinical setting, and full-time prfessinals engaged in health care practitiner ccupatins and health supprt ccupatins, as such terms are defined by the Bureau f Labr Statistics), (9) public educatin, (10) public library services, (11) schl library services, r (12) ther schl-based services. Qualifying payments are separate, n-time, full mnthly payments made n a Direct Lan after Octber 1, 2007 under a qualifying repayment plan. Qualifying emplyment includes an AmeriCrps psitin, a Peace Crps psitin, r emplyment at a public service rganizatin. Qualifying repayment plans include: The Incme-Based Repayment Plan; The Pay As Yu Earn Plan; The Incme-Cntingent Repayment Plan; The 10-Year Standard Repayment Plan (Standard Repayment Plan with a maximum 10-year repayment perid); and Any ther Direct Lan repayment plan, but nly if payments are at least equal t the mnthly payment amunt that wuld be required under the Standard Repayment Plan with a 10-year repayment perid. Page 3 f 6
4 SECTION 7: WHERE TO SEND THE COMPLETED FORM Return the cmpleted frm t: U.S. Department f Educatin FedLan Servicing Or Fax t: P.O. Bx Harrisburg, PA SECTION 8: IMPORTANT INFORMATION ABOUT PSLF Yu may btain lan frgiveness under this prgram if: Yu make 120 qualifying payments (see Payment Eligibility ); On eligible lans (see Lan Eligibility ); While wrking in qualifying emplyment (see Emplyment Eligibility ). Payment Eligibility T receive PSLF, yu must make 120 n-time, full, scheduled, separate mnthly payments n yur Direct Lans under a qualifying repayment plan after Octber 1, On-time payments are thse that are received by the Department n later than 15 days after the scheduled payment due date. Full payments are payments n yur Direct Lan in an amunt that equals r exceeds the amunt yu are required t pay each mnth under yur repayment schedule. If yu make a payment that is less than what yu are required t pay fr that mnth, that mnth's payment will nt cunt as ne f the required 120 qualifying payments. If yu make multiple, partial payments in a mnth and the ttal f thse partial payments equals r exceeds the required full mnthly payment amunt, thse payments will cunt as ne qualifying payment. Scheduled payments are thse that are made while yu are in repayment. They d nt include payments made while yur lans are in an in-schl r grace status, in a deferment r frbearance perid, r if yur lan is paid ahead because yu have made prepayment. Yu must make separate mnthly payments. Lump sum payments r payments yu make as advance payments fr future mnths d nt cunt as mre than ne qualifying payment. If yu wish t make a payment in excess f yur scheduled mnthly payment, fllw the instructins n yur bill fr prviding payment instructins, and ntate that yur payment is nt intended t cver future installments. Otherwise, yur excess payment may affect yur ability t make future qualifying payments. If yu were an AmeriCrps r Peace Crps vlunteer, yu may receive credit fr making qualifying payments if yu make a lump sum payment by using all r part f a Segal If yu need help cmpleting this frm, call: If yu are calling internatinally, call: If yu use a telecmmunicatin device fr the hearing r speach impaired: (TTY), dial: 711 and enter when prmpted. Web site: Educatin Award r Peace Crps transitin payment. The Department will cnsider the lump sum payment yu have made as the equivalent f qualifying payments equal t the lesser f (1) the number f payments resulting after dividing the amunt f the lump sum payment by the mnthly payment amunt yu wuld have made under ne f the qualifying repayment plans listed belw; r (2) 12 payments. Peace Crps vlunteers making an eligible lump sum payment must d s within 6 mnths f the Emplyment End Date, as reprted in Sectin 3. Yur payments must be made under a qualifying repayment plan. Qualifying repayment plans include: The Incme-Based Repayment (IBR) Plan; The Pay As Yu Earn Repayment Plan; The Incme Cntingent Repayment (ICR) Plan; The 10-Year Standard Repayment Plan; r Any ther Direct Lan repayment plan, but nly payments that are at least equal t the mnthly payment amunt that wuld be required under the 10-Year Standard Repayment Plan. Thugh repayment plans ther than the IBR, Pay As Yu Earn, and ICR Plan are qualifying repayment plans fr PSLF, yu must enter IBR, Pay As Yu Earn, r ICR t have a remaining balance t frgive after becming eligible fr PSLF. Otherwise, yur lans will be fully repaid within 10 years. T apply fr these plans, visit StudentLans.gv. IMPORTANT: The Standard Repayment Plan fr Direct Cnslidatin Lans made n r after July 1, 2006 have repayment perids f different lengths. Mnthly payments yu make under the Standard Repayment Plan n such Direct Cnslidatin Lans are nly qualifying payments if the lans have a 10-year repayment perid (which wuld nly ccur if yur ttal educatin indebtedness is less than $7,500). Lan Eligibility Only Direct Lan Prgram lans that are nt in default are eligible fr PSLF. Lans yu received under the Federal Family Educatin Lan (FFEL) Prgram, the Federal Perkins Lan (Perkins Lan) Prgram, r any ther student lan prgram are nt eligible fr PSLF. Page 4 f 6
5 SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED) If yu have FFEL Prgram r Perkins Lan Prgram lans, yu may cnslidate them int a Direct Cnslidatin Lan t take advantage f PSLF. Hwever, payments made n yur FFEL Prgram r Perkins Lan Prgram lans befre yu cnslidated them, even if they were made under a qualifying repayment plan, d nt cunt as qualifying PSLF payments. In additin, if yu made qualifying payments n a Direct Lan and then cnslidate it int a Direct Cnslidatin Lan, yu must start ver making qualifying payments n the new Direct Cnslidatin Lan. If yu cnslidate yur FFEL Prgram r Perkins Lan Prgram lans int a Direct Cnslidatin Lan t take advantage f PSLF and d nt have any Direct Lans, d nt submit this frm until yu have cnslidated yur lans. The applicatin fr Direct Cnslidatin Lans cntains a sectin that allws yu t indicate that yu are cnslidating yur lans fr PSLF. Yu can cnslidate yur federal student lans nline by visiting StudentLans.gv. If yu dn't knw what type f federal student lans yu have, check the Natinal Student Lan Data System (NSLDS) at nslds.ed.gv. Emplyment Eligibility T qualify fr PSLF, yu must be an emplyee f a qualifying rganizatin. An emplyee is smene wh is hired and paid by the rganizatin. Yu may physically perfrm yur wrk at a qualifying r nn-qualifying rganizatin, s lng as yur emplyer is a qualifying rganizatin. If yu are a cntracted emplyee, the rganizatin that hired and pays yu must qualify, nt the rganizatin where yu perfrm yur wrk. The type r nature f emplyment with the rganizatin des nt matter fr PSLF purpses. A qualifying rganizatin is a Federal, State, r lcal gvernment agency, entity, r rganizatin r a taxexempt rganizatin under Sectin 501(c)(3) f the Internal Revenue Cde (IRC). Service in an AmeriCrps r Peace Crps psitin is als qualifying emplyment. The type f services that these rganizatins prvide des nt matter fr PSLF purpses. A private nt-fr-prfit rganizatin that is nt a taxexempt rganizatin under Sectin 501(c)(3) f the IRC may be a qualifying rganizatin if it prvides certain specified public services. These services include emergency management, military service, public safety, r law enfrcement services; public health services; public educatin r public library services; schl library and ther schl-based services; public interest law services; early childhd educatin; public service fr individuals with disabilities and the elderly. The rganizatin must nt be a business rganized fr prfit, a labr unin, r a partisan plitical rganizatin. Emplyment as a member f the U.S. Cngress is nt qualifying emplyment. Yu must be emplyed full-time by yur emplyer. Generally, yu must meet yur emplyer's definitin f full-time. Hwever, fr PSLF purpses, that definitin must be at least an annual average f 30 hurs per week. Fr purpses f the full-time requirement, yur qualifying emplyment at a 501(c)(3) rganizatin r a nt-fr-prfit rganizatin des nt include time spent participating in religius instructin, wrship services, r any frm f prselytizing. If yu are a teacher, r ther emplyee f a public service rganizatin, under cntract fr at least eight ut f 12 mnths, yu meet the full-time standard if yu wrk an average f at least 30 hurs per week during the cntractual perid and receive credit by yur emplyer fr a full year's wrth f emplyment. If yu are emplyed in mre than ne qualifying part-time jb simultaneusly, yu may meet the full-time emplyment requirement if yu wrk a cmbined average f at least 30 hurs per week with yur emplyers. Vacatin r leave time prvided by the emplyer r leave taken fr a cnditin that is a qualifying reasn fr leave under the Family and Medical Leave Act f 1993, 29, U.S.C. 2612(a)(1) and (3) is equivalent t hurs wrked in qualifying emplyment. Other Imprtant Infrmatin The submissin f this frm befre yu apply fr PSLF is ptinal. Hwever, if yu wait t submit this frm until yu apply fr PSLF, yu will be required t submit ne frm fr each emplyer that yu want cnsidered tward yur eligibility fr PSLF. If yu submit this frm and yur emplyer qualifies, all f yur lans held by the Department will be transferred t FedLan Servicing. FedLan Servicing will then determine hw many qualifying payments yu made during the perid f qualifying emplyment within the dates prvided in Sectin 3. Yu are nt permitted t apply the same perid f service t receive PSLF and the Teacher Lan Frgiveness, Service in Areas f Natinal Need, and Civil Legal Assistance Attrney Student Lan Repayment prgrams. N brrwer will be eligible fr PSLF until Octber 2017 at the earliest. An applicatin fr PSLF will be made available at a later time. Page 5 f 6
6 SECTION 9: IMPORTANT NOTICES Privacy Act Ntice. The Privacy Act f 1974 (5 U.S.C. 552a) requires that the fllwing ntice be prvided t yu: The authrities fr cllecting the requested infrmatin frm and abut yu are 421 et seq. and 451 et seq. f the Higher Educatin Act f 1965, as amended (20 U.S.C et seq. and 20 U.S.C. 1087a et seq. ) and the authrities fr cllecting and using yur Scial Security Number (SSN) are 428B(f) and 484(a)(4) f the HEA (20 U.S.C (f) and 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the Federal Family Educatin Lan (FFEL) Prgram r the William D. Frd Federal Direct Lan (Direct Lan) Prgram and giving us yur SSN are vluntary, but yu must prvide the requested infrmatin, including yur SSN, t participate. The principal purpses fr cllecting the infrmatin n this frm, including yur SSN, are t verify yur identity, t determine yur eligibility t receive a lan r a benefit n a lan (such as a deferment, frbearance, discharge, r frgiveness) under the FFEL and/r Direct Lan Prgrams, t permit the servicing f yur lan(s), and, if it becmes necessary, t lcate yu and t cllect and reprt n yur lan(s) if yur lan(s) becmes delinquent r defaults. We als use yur SSN as an accunt identifier and t permit yu t access yur accunt infrmatin electrnically. The infrmatin in yur file may be disclsed, n a caseby-case basis r under a cmputer matching prgram, t third parties as authrized under rutine uses in the apprpriate systems f recrds ntices. The rutine uses f this infrmatin include, but are nt limited t, its disclsure t federal, state, r lcal agencies, t private parties such as relatives, present and frmer emplyers, business and persnal assciates, t cnsumer reprting agencies, t financial and educatinal institutins, and t guaranty agencies in rder t verify yur identity, t determine yur eligibility t receive a lan r a benefit n a lan, t permit the servicing r cllectin f yur lan(s), t enfrce the terms f the lan(s), t investigate pssible fraud and t verify cmpliance with federal student financial aid prgram regulatins, r t lcate yu if yu becme delinquent in yur lan payments r if yu default. T prvide default rate calculatins, disclsures may be made t guaranty agencies, t financial and educatinal institutins, r t state agencies. T prvide financial aid histry infrmatin, disclsures may be made t educatinal institutins. T assist prgram administratrs with tracking refunds and cancellatins, disclsures may be made t guaranty agencies, t financial and educatinal institutins, r t federal r state agencies. T prvide a standardized methd fr educatinal institutins t efficiently submit student enrllment statuses, disclsures may be made t guaranty Page 6 f 6 agencies r t financial and educatinal institutins. T cunsel yu in repayment effrts, disclsures may be made t guaranty agencies, t financial and educatinal institutins, r t federal, state, r lcal agencies. In the event f litigatin, we may send recrds t the Department f Justice, a curt, adjudicative bdy, cunsel, party, r witness if the disclsure is relevant and necessary t the litigatin. If this infrmatin, either alne r with ther infrmatin, indicates a ptential vilatin f law, we may send it t the apprpriate authrity fr actin. We may send infrmatin t members f Cngress if yu ask them t help yu with federal student aid questins. In circumstances invlving emplyment cmplaints, grievances, r disciplinary actins, we may disclse relevant recrds t adjudicate r investigate the issues. If prvided fr by a cllective bargaining agreement, we may disclse recrds t a labr rganizatin recgnized under 5 U.S.C. Chapter 71. Disclsures may be made t ur cntractrs fr the purpse f perfrming any prgrammatic functin that requires disclsure f recrds. Befre making any such disclsure, we will require the cntractr t maintain Privacy Act safeguards. Disclsures may als be made t qualified researchers under Privacy Act safeguards. Paperwrk Reductin Ntice. Accrding t the Paperwrk Reductin Act f 1995, n persns are required t respnd t a cllectin f infrmatin unless such cllectin displays a valid OMB cntrl number. The valid OMB cntrl number fr this infrmatin cllectin is Public reprting burden fr this cllectin f infrmatin is estimated t average 30 minutes per respnse, including time fr reviewing instructins, searching existing data surces, gathering and maintaining the data needed, and cmpleting and reviewing the cllectin f infrmatin. The bligatin t respnd t this cllectin is required t btain a benefit in accrdance with 34 CFR If yu have cmments r cncerns regarding the status f yur individual submissin f this frm, please cntact FedLan Servicing directly (see Sectin 7).