I, (Name of Borrower) _________________________, declare that I am unemployed and do not
have any source of taxable income.
I, (Name of Borrower) _________________________, declare my (weekly, bi-weekly, monthly,
yearly) income to be $__________________.
Employer Name ______________________________
Employer Address ______________________________
______________________________
Employer Phone ______________________________
My Social Security number is: ____________________________
Print Name (borrower): _________________________________
Current Address: ____________________________________
____________________________________
Borrower Signature: ____________________________________ Date: ________________
(MM/DD/YYYY)
(If borrower is married)
To whom it may concern:
I, (Name of Spouse) ___________________________, declare that I am unemployed and do not
have any source of taxable income.
I, (Name of Spouse) ___________________________, declare my (weekly, bi-weekly, monthly,
yearly) Income to be $_____________________.
Employer Name ______________________________
Employer Address ______________________________
______________________________
Employer Phone ______________________________
Spouse’s Social Security number is: ____________________________
Print Name (Spouse): ___________________________________
Current Address: ___________________________________
___________________________________
Spouse’s Signature: ____________________________________ Date: _________________
(MM/DD/YYYY)
Self Declaration
For Federal Student Loans Consolidation Representative
To Whom It May Concern: