Employment Certification for Public Service Loan Forgiveness (PSLF)
PUBLIC SERVICE LOAN FORGIVENESS (PSLF):
EMPLOYMENT CERTIFICATION FORM
William D. Ford Federal Direct Loan (Direct Loan) Program
OMB No. 1845-0110
Exp. Date 12/31/2017
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
SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATIONS
Before signing, carefully read the entire form. For more information about PSLF, visit StudentAid.gov/publicservice.
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
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 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.
Borrower Signature Date
Page 1 of 6
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
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 of Birth
Former Name (if any)
I understand that:
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 employment have to be consecutive.
To qualify for PSLF, I must be employed full-time by a qualifying employer or employers 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(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.
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 or employers and the remaining number of qualifying payments I
must make before I am eligible to apply for PSLF.
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.
Employment Certification for Public Service Loan Forgiveness (PSLF) PDF
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