OADC CONTRACTOR ATTESTATION FORM

Part I: Contractor Attestation Form

Date *

First Name *

Last Name *

Have you gone by another name? *

Yes

No

If yes, what name? *

Email Address *

I have the following contractor status: *

Current OADC Contractor

Former OADC Contractor

Please select a start date and end date for the time frame you are requesting be verified in your PSLF application. You may submit multiple requests for different time frames, completing this form for each eligible time frame.

Please submit a separate Attestation form and separate PSLF Employment Verification form for each timeframe you seek to verify.

Start Date (MM/DD/YYYY) * +

End Date (MM/DD/YYYY) * +

Average number of hours as an OADC contractor per week in the above time frame. (This does NOT have to match your Weekly Average CAAPS Report, see Part II). *

Part II: Supporting Worksheet

Please use this worksheet to assist the OADC in verifying your application. In calculating the average number of hours per week you spent providing services as an OADC contractor in Part I, you reviewed, and relied, in whole and in part, on the following sources: (Please check all that apply) *

Please upload the CAAPS Average Weekly Hours Report you received or pulled for this time period here. *

If there are any other documents that you have relied upon that you wish for the OADC to consider, please attach them here.

Is there anything else you would like the OADC to consider about your request for verification?

Part III: Mandatory Attestation

Attestation: For the time periods indicated above, I provided contract services on behalf of the OADC. The average number of hours I provided services per week over the time period for the OADC above is accurate. I hereby certify and attest that the information I have provided is true, complete, and correct to the best of my knowledge and belief. I understand and agree that the OADC will rely on this form and the information I provide herein to complete and sign Section 5A of my PSLF Application. I understand that falsification of this attestation form could result in the termination of my OADC contract.

Signature *

Date (MM/DD/YYYY) * +