SUPPLEMENTAL ALTERNATIVE

DOCUMENTATION OF INCOME
For Section 5 of the Income-Driven
Repayment Plan Request
BORROWER IDENTIFICATION PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK
Complete the following information:
First Name ___________________________________ Last Name ____________________________________
Account Number ________________________
OPTION 1: SIGNED STATEMENT FROM EMPLOYER
Employer completes this Option to certify Borrowers income or Skip to Option 2 for Borrower Self-Certification.
Pay Period (select one) Weekly Bi-Weekly Monthly Semi-Monthly Annually Other ________________
Taxable Income Per Pay Period* $ ____________
Employer ________________________________________________________________________________
Employer Address _________________________________________________________________________
Employer City, State ZIP ____________________________________________________________________
Employer Signature ____________________________________________
Attach the name, address and signature for additional income sources.
OPTION 2: SELF-CERTIFICATION FROM BORROWER
Complete if Borrower is self-certifying income.
Pay Period (select one) Weekly Bi-Weekly Monthly Semi-Monthly Annually Other ________________
Taxable Income Per Pay Period* $ ___________
Name of Income Source ____________________________________________________________________
Address of Income Source __________________________________________________________________
City, State ZIP of Income Source _____________________________________________________________
OPTION 3: SPOUSE SUPPLEMENTAL INCOME INFORMATION
Complete if Section 4B Loan and Income Information for Married Borrowers was completed on the Income-Driven
Repayment Plan Request.
Pay Period (select one) Weekly Bi-Weekly Monthly Semi-Monthly Annually Other ________________
Taxable Income Per Pay Period* $ ___________
Name of Income Source ____________________________________________________________________
Address of Income Source __________________________________________________________________
City, State ZIP of Income Source _____________________________________________________________
BORROWER UNDERSTANDINGS AND CERTIFICATIONS
I understand that:
o If my actual earnings circumstances have changed, I am required to report any change to MOHELA.
o If I am married, I have read and/or completed Section 4B: Loan and Income Information for Married Borrowers of
the Income-Driven Repayment Plan Request.
I certify that:
o All of the information I have provided on this form is true, complete and correct.
Borrower Signature ________________________________________________ Date ________________________
Spouse Signature (if Option 3 is completed)________________________________ Date ________________________
* This document will serve as income documentation when other documentation is not available. You must provide documentation of all
taxable income that you currently receive from all sources (for example, income from employment, unemployment income, dividend
income, interest income, tips, alimony). If you are married and completed Section 4B Loan and Income Information for Married
Borrowers on the Income-Driven Repayment Plan Request or file a joint federal income tax return, you must also provide
documentation of your spouses taxable income. Do not report untaxed income such as Supplemental Security Income, child
support, or federal or state public assistance.
Return the completed form using the contact information below.
phone 888.866.4352 fax 866.222.7060 TDD Dial 711
633 Spirit Drive, Chesterfield, MO 63005-1243
Secure Form Submission on www.mohela.com. Click Contact Us, then Submit a Form