PSLF Application Form

PSLF APPLICATION FORM

WHEREAS

WHEREAS, Borrower Name: declares employment in a public service position and seeks certification that periods of qualifying employment be considered for Public Service Loan Forgiveness under applicable program requirements;

WHEREAS, Employer Name: agrees to verify employment dates and duties for the periods identified in this application and to provide truthful certification to the extent required by law;

WHEREAS, the parties acknowledge that accurate documentation of employment, repayment and qualifying payments is required to establish eligibility for loan forgiveness and that false statements may subject the signer to penalties under applicable law.

BORROWER INFORMATION

LOAN AND PAYMENT INFORMATION

Loan Servicer(s) and account numbers (list each loan separately; include servicer name and account number):

Total number of qualifying payments made to date (as reported by servicer):

EMPLOYMENT CERTIFICATION

Employment start date:    Employment end date (leave blank if current):

Average hours worked per week in the position certified:

Is this position public service as defined for purposes of loan forgiveness? Yes No

SCOPE OF WORK

Describe the scope of public service employment for which certification is requested. Include job responsibilities, percentage of time spent on public service duties, and any supervisory responsibilities. This description will be relied upon to determine whether employment qualifies.

PAYMENT TERMS

The Borrower certifies that qualifying loan payments were made under repayment plans that meet program criteria. Amounts reported below are intended as a record of payments made that the borrower asserts are qualifying payments.

Payment schedule (select one or describe):

Late fee policy for any non-qualified or delinquent payments:

TERM AND TERMINATION

Term start date:    Term end date (if applicable):

Either party may terminate the employer certification or withdraw representations herein by providing written notice to the other party. Notice period: days.

CONFIDENTIALITY

The parties agree to treat information in this Application as confidential to the extent permitted by law. Employer will not disclose sensitive borrower financial information except as required by law or to loan servicers and authorized program administrators for the purpose of verifying employment and payments. Borrower authorizes release of employment and payment information to assist in evaluation of eligibility.

GOVERNING LAW

This Application and any certifications made herein shall be governed by the laws of the state selected below, without giving effect to conflict of law principles.

ENTIRE AGREEMENT

This Application, together with any written attachments or supplemental certifications, constitutes the entire agreement between the Borrower and Certifying Employer with respect to employment certification for loan forgiveness and supersedes all prior understandings. No amendment shall be effective unless in writing and executed by both parties.

CERTIFICATIONS AND REPRESENTATIONS

By signing below, the Borrower certifies that the information provided is true and accurate to the best of Borrower's knowledge, that payments asserted as qualifying were made under repayment plans consistent with program requirements, and that any misrepresentation may subject the signer to penalties.

The Certifying Official occupies the stated position at the Employer, has authority to certify employment information, and certifies that the employment dates and duties described above are accurate and complete.

Borrower affirmations: I affirm that I met the required hours per week for qualifying full-time employment for the periods asserted. I affirm that the payments listed were made and should be considered qualifying payments under program requirements.

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