1. Demographic Information: Social Security Number: You must list your social security number on your application. If you do not have one, complete and return this form. National Provider Identifier Number (NPI): The National Provider Identifier (NPI) is a standard unique identifier for health care professionals available from the Federal Centers for Medicare and Medicaid Services. The NPI is a 10 digit numeric identifier. If you have a NPI number, provide this on your application. Legal Name: List your full name: first, middle, and last. Definition of legal name: "Legal name" is the name appearing on your official certificate of birth or, if your name has changed since birth, on an official marriage certificate or an order by a court. The court must have the legal authority to change your name. We may ask you to prove your legal name. If you use any name other than your legal name on this form, your application may be denied. Birth date: Provide the month, day, and year you were born. Birth place: Provide the city, state, and country where you were born. Address: List the address we should use to send you any information about your license. Be sure to include the city, state, zip code, county, and country. This will be your permanent address with the Department of Health until you notify us of a change. See WAC 246-12-310. Phone, Fax, and Cell Numbers: Enter your phone, fax, and cell numbers, if you have them. Email Address for Test Date (Required): Enter your email address for examination. The examination company will send test date information to this email address. An email address is required by the examination company. Personal Email Address (Optional): Enter your personal email address. Communication sent from the department will be sent to this address. Employer Email (Optional): Enter your employer's email address. Your employer will receive communication sent to you by the department. Other Name(s): List any other names you are or have been known by. If you have a name change after obtaining a credential, you must notify the Department in writing. You must include legal proof of this change. See WAC 246-12-300. F 2: Personal Data Questions: All applicants must answer the same personal data questions on the application. They are focused on your fitness to practice the essential skills of this profession. If you answer "yes" to any questions in this section, you must provide a complete and accurate explanation. You must submit the appropriate documentation as noted in the personal data questions. If you do not provide this, your application is incomplete and it will not be considered. • Question 5 refers to misdemeanors, gross misdemeanors and felonies. You do not have to answer "yes" if you have been cited for traffic infractions. You can get copies of your court records through the county courthouse where the conviction, plea, deferred sentence, or suspended sentence was entered. • Another jurisdiction means any other country, state, federal territory, or military authority in which convictions may have occurred. DOH 675-003 September 2017 Page 2 of 4 F 3: Type of Services Provided: Check all that apply: • Long-term care workers who must become certified home care aides. • Individuals who are not required to be a home care aide, but choose to apply. F 4: Training: List your training program. You must complete a 75-hour course before taking the home care aide certification examinations. F 5: Other License, Certification, or Registration: List all states where you hold or have held a credential. Submit the Credential Verification Form to all states that you list. F 6: AIDS Education and Training Attestation: AIDS education and training is included in the 75 hour basic training course. Read the AIDS education and training attestation. AIDS training may include self-study, direct patient care, courses, or formal training. A minimum of four hours is required. You can find course content in WAC 246-12-270. F 7: Examination: You must complete this section to be scheduled for the required examinations. • Check "Yes" if you are requesting a testing accommodation OR a one on one interpreter in a language that is not listed on page six of the application. • Print and complete the testing accommodations request packet (only page three if requesting an individual interpreter) and submit directly to Prometric at: Prometric, Attn: Washington Home Care Aide Program, 7941 Corporate Dr., Nottingham, MD 21236. Note: Reasonable testing accommodations are available to candidates with documented disabilities recognized under the Americans with Disabilities Act (ADA). Thirty days advance notice is required for all special testing. You will be notified whether your request is approved before testing is scheduled. There is no additional charge for these accommodations. Once we have received notification that your training has been completed, the examination fee has been paid, and all documents have been received by the department; we will notify the examination company Prometric that you are authorized to test and email an examination authorization letter to you. Prometric will email you an admission to test letter with the date, time, and place of the examination. Once you have taken your examination, Prometric will send the department your examination results. Examination retakes are scheduled directly by Prometric. See the Prometric website for more information. F 8: Applicant's Attestation: You must sign and date this for us to process the application. PSLF ECF PUBLIC SERVICE LOAN FORGIVENESS (PSLF): EMPLOYMENT CERTIFICATION FORM 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 Code and 20 U.S.C. 1097. OMB No. 1845-0110 Form Approved Exp. Date 5/31/2020 PSECF - XBCR SECTION 1: BORROWER INFORMATION Please enter or correct the following information. Check this box if any of your information has changed. SSN Name Address City State Zip Code Telephone - Primary Telephone - Alternate Email (Optional) Date of Birth 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 will 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 Borrower SSN SECTION 3: EMPLOYER INFORMATION (TO BE COMPLETED BY THE BORROWER OR EMPLOYER) 1. Employer Name: 2. Federal Employer Identification Number (FEIN) Your employer's Federal EIN may be found on your Wage and Tax Statement (W-2). 3. Employer Address: 4. Employer Website (if any): 5. Employment Begin Date: 6. Employment End Date: OR Still Employed 7. Employment Status: Full-Time Part-Time 8. Hours Per Week (Average) Include vacation, leave time, or any leave taken under the Family Medical Leave Act of 1993. If your employer is a 501(c)(3) or a not-for-profit organization, do not include any hours you spent on religious instruction, worship services, or proselytizing. 9. Is your employer a governmental organization? A governmental organization is a Federal, State, local, or Tribal government organization, agency, or entity, a public child or family service agency, a Tribal college or university, or the Peace Corps or AmeriCorps. Yes - Skip to Section 4. No - Continue to Item 10. 10. Is your employer tax-exempt under Section 501(c)(3) of the Internal Revenue Code (IRC)? If your employer is tax-exempt under another subsection of 501(c) of the IRC, such as 501(c)(4) or 501(c)(6), check "No" to this question. Yes - Skip to Section 4. No - Continue to Item 11. 11. Is your employer a not-for-profit organization that is not tax-exempt under Section 501(c)(3) of the Internal Revenue Code? Yes - Continue to Item 12. No - Your employer does not qualify. 12. Is your employer a partisan political organization or a labor union? Yes - Your employer does not qualify. No - Continue to Item 13. 13. Which of the following services does your employer provide as its primary purpose? Check all that apply and then continue to Section 4. If you you check "None of the above", do not submit this form. Emergency management Military service (See Section 6) Public safety Law enforcement Public interest legal services (See Section 6) Early childhood education (See Section 6) Public service for individuals with disabilities Public service for the elderly Public health (See Section 6) Public education (See Section 6) Public library services School library services Other school-based services 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 Title Official's Phone 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-dayyear (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 payments are separate, on-time, full monthly payments made on an eligible loan after October 1, 2007 under a qualifying repayment plan while employed full-time by a qualifying employer. An on-time payment is a payment made no more than 15 days after the due date for the payment. Eligible loans are loans made under the William D. Ford Federal Direct Loan (Direct Loan) Program that are not in default. Qualifying repayment plans include the Revised Pay As You Earn (REPAYE) plan, the Pay As You Earn (PAYE) plan, the Income-Based Repayment (IBR) plan, the IncomeContingent Repayment (ICR) plan, the Standard Repayment plan with a maximum 10-year repayment period, and any other Direct Loan repayment plan if payments are at least equal to the monthly payment amount that would be required under the Standard Repayment plan with a 10-year repayment period. An employee means an individual who is hired and paid by the qualifying employer. Full-time means working for one or more qualifying employers for the greater of: (1) An annual average of at least 30 hours per week or, for a contractual or employment period of at least 8 months, an average of 30 hours per week; or (2) Unless the qualifying employment is with two or more employers, the number of hours the employer considers full time. An authorized official is an official of a qualifying employer who has access to the borrower's employment or service records and is authorized by the employer to certify the employment status of the organization's employees or former employees, or the service of AmeriCorps or Peace Corps volunteers. Early childhood education includes licensed or regulated child care, Head Start, and State funded prekindergarten. Law enforcement means crime prevention, control or reduction of crime, or the enforcement of criminal law. Military service means service on behalf of the U. S. Armed Forces or the National Guard. Public education includes services that provide educational enrichment or support directly to students or their families in a school or a school-like setting. Public interest legal services refers to legal services that are funded in whole or in part by a local, State, Federal, or Tribal government. Public health includes nurses, nurse practitioners, nurses in a clinical setting, and full-time professionals engaged in health care practitioner occupations and health support occupations, as such terms are defined by the Bureau of Labor Statistics. QUALIFYING PAYMENT DEFINITIONS QUALIFYING EMPLOYMENT DEFINITIONS A Qualifying employer includes the government, a notfor-profit organization that is tax-exempt under Section 501(c)(3) of the Internal Revenue Code, or a private not-forprofit organization that provides certain public services. Serving in an AmeriCorps or Peace Corps position is also qualifying employment. Government includes a Federal, State, local or Tribal government organization, agency or entity; a public child or family service agency; or a Tribal college or university. A private not-for-profit organization is an organization that is not organized for profit, is not a labor union, is not a partisan political organization, and provides at least one of the following public services as its primary purpose: (1) emergency management, (2) military service, (3) public safety, (4) law enforcement, (5) public interest legal services, (6) early childhood education, (7) public service for individuals with disabilities and the elderly, (8) public health, (9) public education, (10) public library services, (11) school library services, or (12) other schoolbased services. AmeriCorps position means a position approved by the Corporation for National and Community Service under Section 123 of the National and Community Service Act of 1990 (42 U.S.C. 12573). Peace Corps position means a full-time assignment under the Peace Corps Act as provided for under 22 U.S.C. 2504. QUALIFYING EMPLOYMENT DEFINITIONS (CONTINUED) Page 3 of 6 A forbearance is a period during which you are allowed to postpone making payments temporarily, allowed an extension of time for making payments, or temporarily allowed to make smaller payments than scheduled. A forbearance can be a mandatory forbearance, meaning that your loan holder must grant the forbearance if you qualify for the forbearance and supply all supporting documentation. A forbearance can also be a discretionary forbearance, meaning that your loan holder may grant the forbearance, but is not required to do so. OTHER DEFINITIONS SECTION 7: WHERE TO SEND THE COMPLETED FORM Return the completed form and any documentation to: Mail to: U.S. Department of Education, FedLoan Servicing, P.O. Box 69184, Harrisburg, PA 17106-9184. Fax to: 717-720-1628. Upload to: MyFedLoan.org/FileUpload, if FedLoan Servicing is already your servicer. If you need help completing this form, call: Domestic: 855-265-4038. International: 717-720-1985. TTY: dial 711, then enter 800-699-2908. Website: MyFedLoan.org. SECTION 8: IMPORTANT INFORMATION ABOUT PSLF You may receive loan forgiveness under this program only after you have made 120 qualifying payments (see "Payment Eligibility") on eligible loans (see "Loan Eligibility" on page 5) while working full-time in qualifying employment (see "Employment Eligibility" on page 5). PAYMENT ELIGIBILITY To receive PSLF, you must make 120 on-time, full, scheduled, separate monthly payments on your Direct Loans under a qualifying repayment plan after October 1, 2007. On-time payments are those that are received by your servicer no later than 15 days after the scheduled payment due date. Full payments are payments on your Direct Loan in an amount that equals or exceeds the amount you are required to pay each month under your repayment schedule. If you make a payment that is less than what you are required to pay for that month, that month's payment will not count as one of the required 120 qualifying payments. If you make multiple, partial payments in a month and the total of those partial payments equals or exceeds the required full monthly payment amount, those payments will count as one qualifying payment. Scheduled payments are those that are made while you are in repayment. They do not include payments made while your loans are in an in-school or grace status, or in a deferment or forbearance period. You must make separate monthly payments. Except as explained below, lump sum payments or payments you make as advance payments for future months do not count as more than one qualifying payment. If you want to pay more than your scheduled monthly payment amount, follow the instructions on your bill to let your servicer know that your payment is not intended to cover future installments. Otherwise, you may not receive credit for future qualifying payments. If you were an AmeriCorps or Peace Corps volunteer, you may receive credit for making qualifying payments if you make a lump sum payment by using all or part of a Segal Education Award or Peace Corps transition payment. You may also receive credit for qualifying payments if a lump sum payment is made on your behalf through a student loan repayment program administered by the U.S. Department of Defense (DOD). If you make a lump sum payment by using an AmeriCorps Segal Education Award or a Peace Corps transition payment, or if a lump sum payment is made on your behalf through a DOD student loan repayment program, the Department will give you credit for qualifying payments equal to the lesser of (1) the number of payments resulting after dividing the amount of the lump sum payment by the monthly payment amount you would have made under one of the qualifying repayment plans listed below; or (2) 12 payments. If you make an eligible lump sum payment using a Peace Corps transition payment, you must do so within 6 months of the Employment End Date, as reported in Section 3. You may only use an AmeriCorps Segal Education Award or Peace Corps transition payment one time to receive credit for more than one qualifying payment towards PSLF. However, lump sum payments made on your behalf under a DOD student loan repayment program may be counted as up to 12 qualifying payments for each year that a lump sum payment is made. Your payments must be made under a qualifying repayment plan. Qualifying repayment plans include the REPAYE plan, the PAYE plan, the IBR plan, the ICR plan, the 10-Year Standard Repayment plan, or any other Direct Loan repayment plan, but only payments that are at least equal to the monthly payment amount that would be required under the10-Year Standard Repayment plan. Though repayment plans other than the REPAYE, PAYE, IBR, and ICR plans are qualifying repayment plans for PSLF, you must enter REPAYE, PAYE, IBR, or ICR to have a remaining balance to forgive after becoming eligible for PSLF. Otherwise, your loans will be fully repaid within 10 years. To apply for these plans, visit StudentLoans.gov. IMPORTANT: The Standard Repayment Plan for Direct Consolidation Loans made on or after July 1, 2006 has repayment periods that range from 10 to 30 years. Monthly payments you make under this plan are qualifying payments only if the repayment period is 10 years, which would be the case only if the total amount of the consolidation loan and your other eligible student loans is less than $7,500. PAYMENT ELIGIBILITY (CONTINUED) Page 4 of 6 SECTION 8: IMPORTANT INFORMATION ABOUT PSLF (CONTINUED) LOAN ELIGIBILITY Only Direct Loan Program loans that are not in default are eligible for PSLF. Loans you received under the Federal Family Education Loan (FFEL) Program, the Federal Perkins Loan (Perkins Loan) Program, or any other student loan program are not eligible for PSLF. If you have FFEL Program or Perkins Loan Program loans, you may consolidate them into a Direct Consolidation Loan to take advantage of PSLF. However, payments made on your FFEL Program or Perkins Loan Program loans before you consolidated them, even if they were made under a qualifying repayment plan, do not count as qualifying PSLF payments. In addition, if you made qualifying payments on a Direct Loan and then consolidate it into a Direct Consolidation Loan, you must start over making qualifying payments on the new Direct Consolidation Loan. If you are planning to consolidate your FFEL Program or Perkins Loan Program loans into a Direct Consolidation Loan to take advantage of PSLF and do not have any Direct Loans, do not submit this form until you have consolidated your loans. The online application for Direct Consolidation Loans contains a section that allows you to indicate that you are consolidating your loans for PSLF. If you plan to consolidate Perkins Loan Program loans, first understand that Perkins Loan Program loans may be cancelled for certain types of public service. If you consolidate a Perkins Loan Program loan, you will no longer be eligible for Perkins cancellation. The online application is available at StudentLoans.gov. If you don't know whether you have Direct Loans, go to StudentAid.gov/login. EMPLOYMENT ELIGIBILITY To qualify for PSLF, you must be an employee of a qualifying employer. An employee is someone who is hired and paid by the employer. You may physically perform your work at a qualifying or non-qualifying organization, as long as you are an employee of a qualifying employer. If you are working at the location of or with an organization under contract with your employer, the organization that hired and pays you must be a qualifying employer, not the organization where you perform your work. A qualifying organization is a government organization, a tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code, or a private not-for-profit organization that provides certain public services. Service in an AmeriCorps or Peace Corps position is also qualifying employment. EMPLOYMENT ELIGIBILITY (CONTINUED) A private not-for-profit organization that is not a taxexempt organization under Section 501(c)(3) of the IRC may be a qualifying organization if it provides certain specified public services. These services include emergency management, military service, public safety, or law enforcement services; public health services; public education or public library services; school library and other school-based services; public interest legal services; early childhood education; public service for individuals with disabilities and the elderly. The organization must not be a business organized for profit, a labor union, or a partisan political organization. Employment as a member of the U.S. Congress is not qualifying employment. You must be employed full-time by your employer. Generally, you must meet your employer's definition of full-time. However, for PSLF purposes, that definition must be at least an annual average of 30 hours per week. For purposes of the full-time requirement, your qualifying employment at a 501(c)(3) organization or a not-for-profit organization does not include time spent participating in religious instruction, worship services, or any form of proselytizing. If you are a teacher or in another position under contract for at least eight out of 12 months, you meet the full-time standard if you work an average of at least 30 hours per week during the contractual period and receive credit by your employer for a full year's worth of employment. If you are employed in more than one qualifying parttime job simultaneously, you may meet the full-time employment requirement if you work a combined average of at least 30 hours per week with your employers. Vacation or leave time provided by the employer or leave taken for a condition that is a qualifying reason for leave under the Family and Medical Leave Act of 1993, 29, U.S.C. 2612(a)(1) and (3) is equivalent to hours worked in qualifying employment. OTHER IMPORTANT INFORMATION If you submit this form and your employer qualifies, all of your loans held by the Department will be transferred to FedLoan Servicing. FedLoan Servicing will then determine how many qualifying payments you made during the period of qualifying employment within the dates provided in Section 3. You are not permitted to apply the same period of service to 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. 552a) requires that the following notice be provided to you: The authorities for collecting the requested information from and about you are §421 et seq., §451 et seq., or §461 of the Higher Education Act of 1965, as amended (20 U.S.C. 1071 et seq., 20 U.S.C. 1087a et seq., or 20 U.S.C. 1087aa et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §§428B(f) and 484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the William D. Ford Federal Direct Loan (Direct Loan) Program, Federal Family Education Loan (FFEL) Program, or Federal Perkins Loan (Perkins Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate. The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the Direct Loan, FFEL, or Federal Perkins Loan Programs, to permit the servicing of your loans, and, if it becomes necessary, to locate you and to collect and report on your loans if your loans become delinquent or default. We also use your SSN as an account identifier and to permit you to access your account information electronically. The information in your file may be disclosed, on a caseby-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loans, to enforce the terms of the loans, to investigate possible fraud and to verify compliance with federal student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions to efficiently submit student enrollment statuses, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies. In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Paperwork Reduction Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0110. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain a benefit in accordance with 34 CFR 685.219. If you have comments or concerns regarding the status of your individual submission of this form, please contact your loan holder directly (see Section 7). Page 6 of 6
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