PUBLIC SERVICE LOAN FORGIVENESS (PSLF) & TEMPORARY OMB No.

1845-0110
Form Approved
EXPANDED PSLF (TEPSLF) CERTIFICATION & APPLICATION Exp. Date 11/30/2023
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
PSLF
Code and 20 U.S.C. 1097.

SECTION 1: BORROWER INFORMATION

Please enter the following information:
SSN:
Date of Birth:
Name:
Address:
City: State: Zip Code:
Telephone – Primary:
Email:

For more information on PSLF, visit [Link]/publicservice. To apply online, visit [Link]/PSLF.
SECTION 2: BORROWER REQUEST, UNDERSTANDINGS, AND CERTIFICATION
I request (1) that the U.S. Department of Education (the Department) consider this form an application for loan forgiveness to determine whether
I qualify for PSLF or TEPSLF, and discharge any qualifying loans that I have, and (2) if none of my loans qualify for PSLF or TEPSLF forgiveness
when I submit this form, determine how many qualifying payments I have made toward PSLF and TEPSLF.
I believe I qualify for forgiveness now and request a forbearance while my application is being processed. I understand this period of
forbearance will not count toward forgiveness, if the Department determines I am not yet eligible for forgiveness.
I understand that:
1. To qualify for forgiveness, I must have made 120 qualifying payments on my Direct Loans while employed full-time by a qualifying
employer. Neither the 120 qualifying payments nor the qualifying employment have to be consecutive.
2. To qualify for forgiveness, I must be employed full-time by a qualifying employer when I apply for forgiveness.
3. By submitting this form, my student loans held by the Department may be transferred to a different loan servicer.
4. If the Department determines that I appear to be eligible for forgiveness, the Department may contact my employer before granting
forgiveness to ensure that I was employed by the employer at the time I applied for forgiveness.
5. If I am eligible for forgiveness, the amount forgiven will be the principal and interest that was due on my eligible Direct Loans when I
made my final qualifying payment. Any amount that I pay on those loans after I have made my final qualifying payment will be treated
as an overpayment. I must continue to make payments on any of my other loans.
6. If I am not yet eligible for forgiveness, I will be notified of the determination, why it was made, and how many qualifying payments I
have made toward PSLF and TEPSLF. If I requested my loans be placed in forbearance while this determination was being made, they
will be placed back into repayment.
I certify that all 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's Signature Date

(mm/dd/yyyy)
Pages 1 and 2 of this form must be completed in their entirety.

Page 1 of 9
Borrower Name Borrower SSN
SECTION 3: BEFORE YOU BEGIN
• We highly recommend that you complete this form online by going to [Link]/pslf. Doing so allows you to search for your
employer using the PSLF Employer Database to prepopulate this form. You are also able to submit this form if your employer
electronically certifies your employment.
• You should complete this form annually or any time you change employers or have a change in your employment status.
• Review the instructions in Section 6 before you complete the remainder of this form.
SECTION 4: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
1. Federal Employer Identification Number (FEIN/EIN):
2. Employer Name:
3. Employer Address:
Street:
City, State, Zip Code:
Employer Website (if any):
4. Employment Period:
Employment or Certification Begin Date:
(mm/dd/yyyy)
Employment or Certification End Date: OR Still Employed
(mm/dd/yyyy)
5. Employment Status: Full-Time Part-Time
6. Average hours per week:
Check this box if your employer cannot be contacted because the organization has closed or is unable to certify your
employment, and skip to Section 5B.
SECTION 5A: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)
Terms in Bold are defined in Section 7.

By providing an acceptable signature below, I certify that (1) the information in Section 4 is true, complete, and correct to the best of my knowledge
and belief (see Section 6 for instructions), (2) I am an authorized official of the organization named in Section 4, and (3) the borrower named in
Section 1 is or was a direct employee of the organization named in Section 4; or is or was employed under a contract or by a contracted
organization in a position or providing services that, under applicable state law, cannot be filled or provided by a direct employee of the organization
named in Section 4.
Note: If any of the information is crossed out or altered in Section 4 or 5A, the authorized official must initial those changes.

Official's Name: Official's Phone:

Official's Title: Official's Email:

Authorized Official's Signature Date

(mm/dd/yyyy)
SECTION 5B: ALTERNATIVE DOCUMENTATION FOR EMPLOYMENT CERTIFICATION (only if Section 5A cannot be completed)
If you cannot obtain certification from your employer because the organization is closed or because the organization is unable to certify your
employment and indicated that by checking the box above on this form, you can submit alternative documentation that may allow your employment
to be certified. See Section 6 for more information. If this form is submitted without the necessary supporting documents, the PSLF servicer will
contact you to request additional information before your employment can be certified.

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