Student Loan Payment Certification

Employers can provide retirement plan matches based on qualified student loan payments certified by the employee or made directly through payroll deduction. This form is used to certify student loan payments for the employer's match under the certification model only.

Employee First Name

Employee Last Name

Employee SSN

Employee DOB

Employee Email Address

Current Employer Name

Current Employer City

State

Loan Number

Submit a separate form for each qualified student loan on which you made payments during calendar year 2024.

Number Payments made this year

Payment 1 Date

Identify the date and corresponding amount for each qualified student loan payment made during the calendar year 2024.

Payment 1 Amount

Payment 2 Date

Payment 2 Amount

Payment 3 Date

Payment 3 Amount

Payment 4 Date

Payment 4 Amount

Payment 5 Date

Payment 5 Amount

Payment 6 Date

Payment 6 Amount

Payment 7 Date

Payment 7 Amount

Payment 8 Date

Payment 8 Amount

Payment 9 Date

Payment 9 Amount

Payment 10 Date

Payment 10 Amount

Payment 11 Date

Payment 11 Amount

Payment 12 Date

Payment 12 Amount

I made the student loan payments identified above.

Yes

The student loan identified above is a qualified education loan used to pay for qualified higher education expenses of me, my spouse, or my dependent.

Yes

I incurred the student loan identified above.

(Under IRS guidance, an employee incurs a loan if he or she is the primary borrower or a cosigner. A guarantor is only deemed to have incurred a loan if the guarantor is legally obligated to make the payment because of the primary borrower's default.)

Yes