You're not done yet. Action is required.

PRINT, COMPLETE, AND SUBMIT THIS FORM FOR PROCESSING.

STEP 1: Download and print the form.

STEP 2: Read and sign the form.

STEP 3: Have your employer read and sign the form.

STEP 4: Submit the form that you and your employer have signed in one of the following ways:

Mail to:
U.S. Department of Education, FedLoan Servicing, P.O. Box 69184, Harrisburg, PA 17106-9184.

Fax to:
717-720-1628

An email has been sent to [email protected] for your records.

Note: After you leave this page, these instructions and your PSLF form will be available in the "My Documents" section of
StudentAid.gov.

What will happen after you submit this form for processing?
Once FedLoan Servicing receives your form, they will begin their review. Once they review your employment, the number
of qualifying payments that you've made will be determined and then you'll receive a notice telling you the number of
qualifying payments you've made.

Note: It may take up to 120 days to process your employment information and review your payment information.

You will not receive confirmation that your loan, employment, or payments qualify for PSLF until you submit this form.

Reminder: You should submit an Employment Certification Form annually to be sure that you're on track to receive PSLF.

Some of your loans do not qualify for the PSLF Program, but there are actions you could consider taking
As we shared previously, some of your loans do not qualify for the PSLF Program. However, there are actions you could
consider taking that would allow you to get a greater benefit out of the PSLF Program. Here are those actions again and
the loans to which they apply.

CONSOLIDATE SOME OF YOUR LOANS

As a reminder, not all of your loans currently qualify for PSLF.

• You have loans under other federal student loan programs, such as the Federal Family Education Loan (FFEL)
Program or the Federal Perkins Loan (Perkins Loan) Program.
Loans from these programs do not qualify for PSLF, but they may become eligible if you consolidate them into a
Direct Consolidation Loan.

Below is the list of loans you may want to consolidate so that all of your loans qualify for PSLF
 Loan Outstanding
Loan Type Loan Date
Code Balance

Unsubsidized FFEL Stafford Loan (including Nonsubsidized Stafford

G 01/30/2007 $2,089
Loan)

Subsidized FFEL Stafford Loan A 10/08/2007 $7,812

Subsidized FFEL Stafford Loan A 01/30/2007 $2,916

Subsidized FFEL Stafford Loan A 10/05/2006 $5,103

Unsubsidized FFEL Stafford Loan (including Nonsubsidized Stafford

G 10/05/2006 $8,451
Loan)

Unsubsidized FFEL Stafford Loan (including Nonsubsidized Stafford

G 10/08/2007 $10,019
Loan)

Subsidized FFEL Stafford Loan A 09/14/2005 $3,990

Important: If you choose to consolidate your other federal student loans, none of the payments you made prior to
consolidating will qualify towards PSLF. This means that, if you consolidate

• you must make 120 qualifying payments on the new consolidation loan to qualify for PSLF; and
• you will not be eligible for forgiveness on your new consolidation loan until at least 10 years after you consolidate.

Knowing this, if you are still interested in the PSLF Program, you should take the following steps:

• Consolidate only your FFEL and Perkins loans.

• If you’re interested in Perkins Loan Cancellation, you may not want to include your Perkins Loans in your
consolidation because you will lose those loan cancellation benefits.
• Within the consolidation application, all of your loans will automatically be included for consolidation. You should
uncheck any loan types that you do not want to consolidate. You can use the loan type codes in the table above to
assist you in ensuring only the appropriate loans are consolidated.
• When asked to select a repayment plan within the consolidation application, choose the Pay As You Earn (PAYE)
Plan to get the most benefit out of the PSLF Program.

Consolidate Now: https://studentaid.gov/app/launchConsolidation.action

SOME OF YOUR LOANS ARE IN DEFAULT.

As a reminder, some of your Direct Loans are in default and some are not.

• Your defaulted Direct Loans do not qualify for PSLF, and you cannot currently make qualifying payments needed
for PSLF eligibility.

Below is the list of loans that are in default.

Loan Type Loan Code Loan Date Outstanding Balance

Direct Subsidized Consolidation Loan E 11/13/2013 $12,738

Direct Unsubsidized Consolidation Loan K 11/13/2013 $47,263

We encourage you to do the following:

• Learn more about removing your loans from default.
• When you’re ready to remove your loans from default, visit myeddebt.ed.gov or call 1-800-621-3115 to get started.
 OMB No. 1845-0110
PUBLIC SERVICE LOAN FORGIVENESS (PSLF): Form Approved
EMPLOYMENT CERTIFICATION FORM Exp. Date 5/31/2020
William D. Ford Federal Direct Loan (Direct Loan) Program PSECF - XBCR

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on
PSLF ECF 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 INFORMATION
Please enter or correct the following information.
Check this box if any of your information has changed.
SSN 139807488
Date of Birth 05/06/1986
Name MURIAH MOULTRIE
Address 93 Straight Street apt 3B
City Paterson State NJ Zip Code 07501
Telephone - Primary
Telephone - Alternate (973) 413-5954
Email (Optional) [email protected]

SECTION 2: BORROWER AUTHORIZATIONS, UNDERSTANDINGS, AND CERTIFICATION

Before signing, carefully read the entire form. For more information on PSLF, visit StudentAid.gov/publicservice.
I authorize:
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 Loans 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 Loans will be forgiven.
4. By submitting this form, my student loan(s) held by the Department may 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. I will be notified if the form that I submit is incomplete, or if my employment or payments do not qualify for PSLF, why the
determination was made, 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.

Borrower's Signature Date

Page 1 of 6
 Borrower Name MURIAH MOULTRIE Borrower SSN 139807488
SECTION 3: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER)
1. Employer Name 10. Is your employer tax-exempt under Section 501(c)(3) of
Pcbss the Internal Revenue Code (IRC)?
If your employer is tax-exempt under another subsection
2. Federal Employer Identification Number (FEIN) of 501(c) of the IRC, such as 501(c)(4) or 501(c)(6),
226002469 check "No" to this question.

Your employer's Federal EIN may be found on your Yes - Skip to Section 4.
Wage and Tax Statement (W-2). No - Continue to Item 11.

3. Employer Address: 11. Is your employer a not-for-profit organization that is not

tax-exempt under Section 501(c)(3) of the Internal
80 Hamilton Street Revenue Code?
Paterson, NJ 07505 US
Yes - Continue to Item 12.
No - Your employer does not qualify.

12. Is your employer a partisan political organization or a

4. Employer Website (if any):
labor union?
93 Straight Street
Yes - Your employer does not qualify.
5. Employment Begin Date: No - Continue to Item 13.
09/04/2018
13. Which of the following services does your employer
6. Employment End Date: provide as its primary purpose? Check all that apply and
OR X Still Employed then continue to Section 4. If you you check "None of the
above", do not submit this form.
7. Employment Status: X Full-Time Part-Time
Emergency management
8. Hours Per Week (Average) 35 Military service (See Section 6)
Public safety
Include vacation, leave time, or any leave taken under
Law enforcement
the Family Medical Leave Act of 1993. If your employer is
a 501(c)(3) or a not-for-profit organization, do not include Public interest legal services (See Section 6)
any hours you spent on religious instruction, worship Early childhood education (See Section 6)
services, or proselytizing. Public service for individuals with disabilities
9. Is your employer a governmental organization? Public service for the elderly
Public health (See Section 6)
A governmental organization is a Federal, State, local,
Public education (See Section 6)
or Tribal government organization, agency, or entity, a
public child or family service agency, a Tribal college or Public library services
university, or the Peace Corps or AmeriCorps. School library services
X Yes - Skip to Section 4. Other school-based services
No - Continue to Item 10. None of the above - the employer does not qualify.
SECTION 4: EMPLOYER CERTIFICATION (TO BE COMPLETED BY THE EMPLOYER)
By signing, I certify (1) that the information in Section 3 is true, complete, and correct to the best of my knowledge and belief, (2)
that I am an authorized official (see Section 6) of the organization named in Section 3, and (3) that the borrower named in Section
1 is or was an employee of the organization named in Section 3.
Note: If any of the information is crossed out or altered in Section 3, you must initial those changes.
Official's Name Official's Phone
Official's Title Official's Email

Authorized Official's Signature Date

Page 2 of 6
SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM
If you have made 120 qualifying payments and the certification in Sections 3 and 4 does not cover all of those payments, you
must provide information about other employers by submitting one copy of Sections 1 and 2 (Page 1), and one copy of Sections 3
and 4 (Page 2) per employer. When completing this form, type or print using dark ink. Enter dates as month-day-year (mm-dd-
yyyy). Use only numbers. Example: March 14, 2016 = 03-14-2016. For more information about PSLF and how to use this form,
visit StudentAid.gov/publicservice. Return the completed form to the address shown in Section 7.
SECTION 6: DEFINITIONS
QUALIFYING PAYMENT DEFINITIONS QUALIFYING EMPLOYMENT DEFINITIONS (CONTINUED)
Qualifying payments are separate, on-time, full monthly An employee means an individual who is hired and paid by
payments made on an eligible loan after October 1, 2007 the qualifying employer.
under a qualifying repayment plan while employed full-time by Full-time means working for one or more qualifying
a qualifying employer. employers for the greater of: (1) An annual average of at least
An on-time payment is a payment made no more than 15 30 hours per week or, for a contractual or employment period
days after the due date for the payment. of at least 8 months, an average of 30 hours per week; or (2)
Eligible loans are loans made under the William D. Ford Unless the qualifying employment is with two or more
Federal Direct Loan (Direct Loan) Program that are not in employers, the number of hours the employer considers full
default. time.
Qualifying repayment plans include the Revised Pay As An authorized official is an official of a qualifying employer
You Earn (REPAYE) plan, the Pay As You Earn (PAYE) plan, who has access to the borrower's employment or service
the Income-Based Repayment (IBR) plan, the Income- records and is authorized by the employer to certify the
Contingent Repayment (ICR) plan, the Standard Repayment employment status of the organization's employees or former
plan with a maximum 10-year repayment period, and any employees, or the service of AmeriCorps or Peace Corps
other Direct Loan repayment plan if payments are at least volunteers.
equal to the monthly payment amount that would be required Early childhood education includes licensed or regulated
under the Standard Repayment plan with a 10-year child care, Head Start, and State funded pre-kindergarten.
repayment period. Law enforcement means crime prevention, control or
reduction of crime, or the enforcement of criminal law.
QUALIFYING EMPLOYMENT DEFINITIONS Military service means service on behalf of the U. S.
A Qualifying employer includes the government, a not-for- Armed Forces or the National Guard.
profit organization that is tax-exempt under Section 501(c)(3) Public education includes services that provide
of the Internal Revenue Code, or a private not-for-profit educational enrichment or support directly to students or their
organization that provides certain public services. Serving in families in a school or a school-like setting.
an AmeriCorps or Peace Corps position is also qualifying Public interest legal services refers to legal services that
employment. are funded in whole or in part by a local, State, Federal, or
Government includes a Federal, State, local or Tribal Tribal government.
government organization, agency or entity; a public child or Public health includes nurses, nurse practitioners, nurses
family service agency; or a Tribal college or university. in a clinical setting, and full-time professionals engaged in
A private not-for-profit organization is an organization health care practitioner occupations and
that is not organized for profit, is not a labor union, is not a health support occupations, as such terms are defined by the
partisan political organization, and provides at least one of the Bureau of Labor Statistics.
following public services as its primary purpose: (1)
emergency management, (2) military service, (3) public safety, OTHER DEFINITIONS
(4) law enforcement, (5) public interest legal services, (6) early A forbearance is a period during which you are allowed to
childhood education, (7) public service for individuals with postpone making payments temporarily, allowed an extension
disabilities and the elderly, (8) public health, (9) public of time for making payments, or temporarily allowed to make
education, (10) public library services, (11) school library smaller payments than scheduled. A forbearance can be a
services, or (12) other school-based services. mandatory forbearance, meaning that your loan holder must
AmeriCorps position means a position approved by the grant the forbearance if you qualify for the forbearance and
Corporation for National and Community Service under supply all supporting documentation. A forbearance can also
Section 123 of the National and Community Service Act of be a discretionary forbearance, meaning that your loan holder
1990 (42 U.S.C. 12573). may grant the forbearance, but is not required to do so.
Peace Corps position means a full-time assignment under
the Peace Corps Act as provided for under 22 U.S.C. 2504.

Page 3 of 6
SECTION 7: WHERE TO SEND THE COMPLETED FORM
Return the completed form and any documentation to: If you need help completing this form, call:

Mail to: U.S. Department of Education, FedLoan Servicing, Domestic: 855-265-4038.

P.O. Box 69184, Harrisburg, PA 17106-9184. International: 717-720-1985.
TTY: dial 711, then enter 800-699-2908.
Fax to: 717-720-1628.
Website: MyFedLoan.org.
Upload to: MyFedLoan.org/FileUpload, if FedLoan
Servicing is already your servicer.

SECTION 8: IMPORTANT INFORMATION ABOUT PSLF

You may receive loan forgiveness under this program only PAYMENT ELIGIBILITY (CONTINUED)
after you have made 120 qualifying payments (see "Payment If you make a lump sum payment by using an AmeriCorps
Eligibility") on eligible loans (see "Loan Eligibility" on page 5) Segal Education Award or a Peace Corps transition payment,
while working full-time in qualifying employment (see or if a lump sum payment is made on your behalf through a
"Employment Eligibility" on page 5). DOD student loan repayment program, the Department will
PAYMENT ELIGIBILITY give you credit for qualifying payments equal to the lesser of
To receive PSLF, you must make 120 on-time, full, (1) the number of payments resulting after dividing the amount
scheduled, separate monthly payments on your Direct Loans of the lump sum payment by the monthly payment amount you
under a qualifying repayment plan after October 1, 2007. would have made under one of the qualifying repayment plans
On-time payments are those that are received by your listed below; or (2) 12 payments.
servicer no later than 15 days after the scheduled payment If you make an eligible lump sum payment using a Peace
due date. Corps transition payment, you must do so within 6 months of
Full payments are payments on your Direct Loan in an the Employment End Date, as reported in Section 3.
amount that equals or exceeds the amount you are required to You may only use an AmeriCorps Segal Education Award
pay each month under your repayment schedule. If you make or Peace Corps transition payment one time to receive credit
a payment that is less than what you are required to pay for for more than one qualifying payment towards PSLF.
that month, that month's payment will not count as one of the However, lump sum payments made on your behalf under a
required 120 qualifying payments. If you make multiple, partial DOD student loan repayment program may be counted as up
payments in a month and the total of those partial payments to 12 qualifying payments for each year that a lump sum
equals or exceeds the required full monthly payment amount, payment is made.
those payments will count as one qualifying payment. Your payments must be made under a qualifying repayment
Scheduled payments are those that are made while you are plan. Qualifying repayment plans include the REPAYE plan,
in repayment. They do not include payments made while your the PAYE plan, the IBR plan, the ICR plan, the 10-Year
loans are in an in-school or grace status, or in a deferment or Standard Repayment plan, or any other Direct Loan
forbearance period. repayment plan, but only payments that are at least equal to
You must make separate monthly payments. Except as the monthly payment amount that would be required under the
explained below, lump sum payments or payments you make 10-Year Standard Repayment plan.
as advance payments for future months do not count as more Though repayment plans other than the REPAYE, PAYE,
than one qualifying payment. If you want to pay more than IBR, and ICR plans are qualifying repayment plans for PSLF,
your scheduled monthly payment amount, follow the you must enter REPAYE, PAYE, IBR, or ICR to have a
instructions on your bill to let your servicer know that your remaining balance to forgive after becoming eligible for PSLF.
payment is not intended to cover future installments. Otherwise, your loans will be fully repaid within 10 years. To
Otherwise, you may not receive credit for future qualifying apply for these plans, visit StudentLoans.gov.
payments.
If you were an AmeriCorps or Peace Corps volunteer, you IMPORTANT: The Standard Repayment Plan for Direct
may receive credit for making qualifying payments if you make Consolidation Loans made on or after July 1, 2006 has
a lump sum payment by using all or part of a Segal Education repayment periods that range from 10 to 30 years. Monthly
Award or Peace Corps transition payment. payments you make under this plan are qualifying payments
You may also receive credit for qualifying payments if a only if the repayment period is 10 years, which would be the
lump sum payment is made on your behalf through a student case only if the total amount of the consolidation loan and
loan repayment program administered by the U.S. Department your other eligible student loans is less than $7,500.
of Defense (DOD).

Page 4 of 6
SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED)
LOAN ELIGIBILITY EMPLOYMENT ELIGIBILITY (CONTINUED)
Only Direct Loan Program loans that are not in default are A private not-for-profit organization that is not a tax-exempt
eligible for PSLF. Loans you received under the Federal organization under Section 501(c)(3) of the IRC may be a
Family Education Loan (FFEL) Program, the Federal Perkins qualifying organization if it provides certain specified public
Loan (Perkins Loan) Program, or any other student loan services. These services include emergency management,
program are not eligible for PSLF. military service, public safety, or law enforcement services;
If you have FFEL Program or Perkins Loan Program loans, public health services; public education or public library
you may consolidate them into a Direct Consolidation Loan to services; school library and other school-based services;
take advantage of PSLF. However, payments made on your public interest legal services; early childhood education; public
FFEL Program or Perkins Loan Program loans before you service for individuals with disabilities and the elderly. The
consolidated them, even if they were made under a qualifying organization must not be a business organized for profit, a
repayment plan, do not count as qualifying PSLF payments. In labor union, or a partisan political organization.
addition, if you made qualifying payments on a Direct Loan Employment as a member of the U.S. Congress is not
and then consolidate it into a Direct Consolidation Loan, you qualifying employment.
must start over making qualifying payments on the new Direct You must be employed full-time by your employer.
Consolidation Loan. Generally, you must meet your employer's definition of full-
If you are planning to consolidate your FFEL Program or time. However, for PSLF purposes, that definition must be at
Perkins Loan Program loans into a Direct Consolidation Loan least an annual average of 30 hours per week. For purposes
to take advantage of PSLF and do not have any Direct Loans, of the full-time requirement, your qualifying employment at a
do not submit this form until you have consolidated your loans. 501(c)(3) organization or a not-for-profit organization does not
The online application for Direct Consolidation Loans contains include time spent participating in religious instruction, worship
a section that allows you to indicate that you are consolidating services, or any form of proselytizing.
your loans for PSLF. If you plan to consolidate Perkins Loan If you are a teacher or in another position under contract for
Program loans, first understand that Perkins Loan Program at least eight out of 12 months, you meet the full-time
loans may be cancelled for certain types of public service. If standard if you work an average of at least 30 hours per week
you consolidate a Perkins Loan Program loan, you will no during the contractual period and receive credit by your
longer be eligible for Perkins cancellation. The online employer for a full year's worth of employment.
application is available at StudentLoans.gov. If you don't know If you are employed in more than one qualifying part-time
whether you have Direct Loans, go to StudentAid.gov/login. job simultaneously, you may meet the full-time employment
requirement if you work a combined average of at least 30
EMPLOYMENT ELIGIBILITY hours per week with your employers.
To qualify for PSLF, you must be an employee of a Vacation or leave time provided by the employer or leave
qualifying employer. An employee is someone who is hired taken for a condition that is a qualifying reason for leave under
and paid by the employer. You may physically perform your the Family and Medical Leave Act of 1993, 29, U.S.C.
work at a qualifying or non-qualifying organization, as long as 2612(a)(1) and (3) is equivalent to hours worked in qualifying
you are an employee of a qualifying employer. If you are employment.
working at the location of or with an organization under
contract with your employer, the organization that hired and OTHER IMPORTANT INFORMATION
pays you must be a qualifying employer, not the organization Your servicer will determine how many qualifying payments
where you perform your work. you made during the period of qualifying employment within
A qualifying organization is a government organization, a the dates provided in Section 3. If you submit this form and
tax-exempt organization under Section 501(c)(3) of the your employer qualifies, all of your loans held by the
Internal Revenue Code, or a private not-for-profit organization Department may be transferred to FedLoan Servicing as you
that provides certain public services. Service in an approach the date that you may qualify for forgiveness.
AmeriCorps or Peace Corps position is also qualifying You are not permitted to apply the same period of service to
employment. receive PSLF and the Teacher Loan Forgiveness and Civil
Legal Assistance Attorney Student Loan Repayment
programs.

Page 5 of 6
SECTION 9: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. To assist program administrators with tracking refunds and
552a) requires that the following notice be provided to you: cancellations, disclosures may be made to guaranty agencies,
The authorities for collecting the requested information from to financial and educational institutions, or to federal or state
and about you are §421 et seq., §451 et seq., or §461 of the agencies. To provide a standardized method for educational
Higher Education Act of 1965, as amended (20 U.S.C. 1071 et institutions to efficiently submit student enrollment statuses,
seq., 20 U.S.C. 1087a et seq., or 20 U.S.C. 1087aa et seq.) disclosures may be made to guaranty agencies or to financial
and the authorities for collecting and using your Social and educational institutions. To counsel you in repayment
Security Number (SSN) are §§428B(f) and 484(a)(4) of the efforts, disclosures may be made to guaranty agencies, to
HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. financial and educational institutions, or to federal, state, or
7701(b). Participating in the William D. Ford Federal Direct local agencies.
Loan (Direct Loan) Program, Federal Family Education Loan In the event of litigation, we may send records to the
(FFEL) Program, or Federal Perkins Loan (Perkins Loan) Department of Justice, a court, adjudicative body, counsel,
Program and giving us your SSN are voluntary, but you must party, or witness if the disclosure is relevant and necessary to
provide the requested information, including your SSN, to the litigation. If this information, either alone or with other
participate. information, indicates a potential violation of law, we may send
The principal purposes for collecting the information on this it to the appropriate authority for action. We may send
form, including your SSN, are to verify your identity, to information to members of Congress if you ask them to help
determine your eligibility to receive a loan or a benefit on a you with federal student aid questions. In circumstances
loan (such as a deferment, forbearance, discharge, or involving employment complaints, grievances, or disciplinary
forgiveness) under the Direct Loan, FFEL, or Federal Perkins actions, we may disclose relevant records to adjudicate or
Loan Programs, to permit the servicing of your loans, and, if it investigate the issues. If provided for by a collective
becomes necessary, to locate you and to collect and report on bargaining agreement, we may disclose records to a labor
your loans if your loans become delinquent or default. We also organization recognized under 5 U.S.C. Chapter 71.
use your SSN as an account identifier and to permit you to Disclosures may be made to our contractors for the purpose
access your account information electronically. of performing any programmatic function that requires
The information in your file may be disclosed, on a case-by- disclosure of records. Before making any such disclosure, we
case basis or under a computer matching program, to third will require the contractor to maintain Privacy Act safeguards.
parties as authorized under routine uses in the appropriate Disclosures may also be made to qualified researchers under
systems of records notices. The routine uses of this Privacy Act safeguards.
information include, but are not limited to, its disclosure to Paperwork Reduction Notice. According to the Paperwork
federal, state, or local agencies, to private parties such as Reduction Act of 1995, no persons are required to respond to
relatives, present and former employers, business and a collection of information unless such collection displays a
personal associates, to consumer reporting agencies, to valid OMB control number. The valid OMB control number for
financial and educational institutions, and to guaranty this information collection is 1845-0110. Public reporting
agencies in order to verify your identity, to determine your burden for this collection of information is estimated to
eligibility to receive a loan or a benefit on a loan, to permit the average 30 minutes per response, including time for reviewing
servicing or collection of your loans, to enforce the terms of instructions, searching existing data sources, gathering and
the loans, to investigate possible fraud and to verify maintaining the data needed, and completing and reviewing
compliance with federal student financial aid program the collection of information. The obligation to respond to this
regulations, or to locate you if you become delinquent in your collection is required to obtain a benefit in accordance with 34
loan payments or if you default. To provide default rate CFR 685.219. If you have comments or concerns regarding
calculations, disclosures may be made to guaranty agencies, the status of your individual submission of this form, please
to financial and educational institutions, or to state agencies. contact your loan holder directly (see Section 7).
To provide financial aid history information, disclosures may
be made to educational institutions.

Page 6 of 6