Public Service Loan Forgiveness (PSLF): Complaint Form 123 This office cannot give legal advice, nor can we represent individual consumers in actions against servicers. Consumer Name*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Military Veteran Status*Are you an active or retired member of the U.S. Armed Forces or a dependent? Yes No BranchU.S. Air ForceU.S. ArmyU.S. Coast GuardMarine CorpNavyMilitary Status*Active Duty Service MemberDependent Spouse - Service MemberDependent Child/Other - Service MemberDoD CivilianDependent Spose - DoD CivilianDependent Child/Other - DoD CivilianMilitary Retiree VeteranInactive Reserve/National Guard Select Loan Servicer*Please select the company that services your loans:FedLoan Servicing (PHEAA)Granite State (GSMR)Great Lakes Educational Loan ServicesHESC/EdFinancialMOHELANavientOSLA ServicingECSICorner STONEDon't KnowOtherIf other, list the Student Loan Servicer name:Type of Loan* Federal Student Loan (Stafford, Direct Subsidized, Direct Unsubsidized, Direct Loan Consolidation, PLUS, Federal Family Education Loan FFEL, Perkins) Private Student Loan (Private, Alternative, or Co-signed Loans; Federal Loans refinanced with a private lender; other Student Loans) Both Don't Know Please Select Repayment Plan*StandardGraduatedExtendedREPAYE - Revised Pay as You Earn Repayment PlanPAYE - Pay As You Earn Repayment PlanIBR - Income Based Repayment PlanICR - Income-Contingent Repayment PlanIncome Sensitive Repayment PlanDon't KnowPayments*Have you made payments toward the 120-payment requirement to qualify for PSLF or TEPSLF? Yes No Don't Know Loan Status*Other than an In-School Deferment or Grace period, have your loans ever been in a deferment, forbearance or default? Yes No Don't Know Summary of Complaint*(for example, include employment history, type of loan and prior servicers, if relevant.)Related Documents* Yes No In order to ensure a timely investigation of your complaint, please include copies of all relevant documents.Upload Files Drop files here or Select files Max. file size: 8 MB. The Privacy Act of 1974, 5 U.S.C. §552a (“the Act”), is a Federal law designed to protect you from unauthorized use and exchange of personal information by Federal agencies and their contractors. Subject to limited exceptions set forth in the Act, Federal agencies and their contractors cannot release information about you to anyone without your written consent.Consent for Information ReleaseBy checking this box, I provide consent to and authorize the servicer named in my complaint to release orally , in writing or electronically to the Office of the Attorney General, Colorado Department of Law (the “Attorney General”), information including but not limited to a complete loan history, call recordings and all necessary requested information about my federal student loan placed by the United States Department of Education with my servicer as necessary to resolve the Complaint/Inquiry filed with the Attorney General. I agree to have my information released.CAPTCHA
