2024 STUDENT LOAN 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 Information

Employee First Name *

Employee Last Name *

Employee SSN *

Employee DOB * +

Employee Email *

Current Employer State *

Current Employer City *

Current Employer Name *

Loan Information

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

Loan Number *

Number of Loan Payments *

Student Loan Payments

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

Payment 1 Date * +

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 *

Payment 13 Date * +

Payment 13 Amount *

Payment 14 Date * +

Payment 14 Amount *

Payment 15 Date * +

Payment 15 Amount *

Payment 16 Date * +

Payment 16 Amount *

Payment 17 Date * +

Payment 17 Amount *

Payment 18 Date * +

Payment 18 Amount *

Payment 19 Date * +

Payment 19 Amount *

Payment 20 Date * +

Payment 20 Amount *

Payment 21 Date * +

Payment 21 Amount *

Payment 22 Date * +

Payment 22 Amount *

Payment 23 Date * +

Payment 23 Amount *

Payment 24 Date * +

Payment 24 Amount *

Total Loan Payments

$0.00

Certification

I certify the following: *

I made the student loan payments identified above.

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.

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.