OMB
No. 1845-0059 Form
Approved Exp.
Date
TLFA |
TEACHER LOAN FORGIVENESS APPLICATION Federal Family Education Loan Program/William D. Ford Federal Direct Loan ProgramYou may qualify for loan forgiveness only if you had no outstanding balance on a Federal Family Education Loan (FFEL) Program loan or a William D. Ford Federal Direct Loan (Direct Loan) Program Loan on October 1, 1998, or had no outstanding balance on a FFEL or Direct Loan program loan on the date you obtained a loan after October 1, 1998. WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying documents is subject to penalties that may include fines, imprisonment or both, under the U.S. Criminal Code and 20 U.S.C. 1097. |
|||||||||||||||||||||||||||||||||
SECTION 1: BORROWER IDENTIFICATION |
||||||||||||||||||||||||||||||||||
|
Please enter or correct the following information. |
|||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||
|
SSN |
|
|
|
- |
|
|
- |
|
|
|
|
|
|||||||||||||||||||||
|
Name |
|
||||||||||||||||||||||||||||||||
|
Address |
|
||||||||||||||||||||||||||||||||
|
City, State, Zip Code |
|
||||||||||||||||||||||||||||||||
|
Telephone - Home |
( ) |
||||||||||||||||||||||||||||||||
|
Telephone - Other |
( ) |
||||||||||||||||||||||||||||||||
|
E-mail (optional) |
|
||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||
SECTION 2: BORROWER’S LOAN FORGIVENESS REQUEST, PREVIOUS LOAN FORGIVENESS INFORMATION, UNDERSTANDINGS, AND CERTIFICATION |
The borrower must complete this section. |
|||||||||||||||||||||||||||||||||
Before completing this section, carefully read the entire form, including the general information and instructions, terms and conditions, definitions, and eligibility requirements in Sections 4, 5, 6, 7, and 8 on this form. Loan Forgiveness Request I request forgiveness on my FFEL and/or Direct Loan Program loan(s) based on my employment as a full-time teacher in an elementary or secondary school for at least five consecutive, complete academic years. (Note: School librarians, guidance counselors, and other administrative staff are not considered teachers for the purposes of this loan forgiveness program.) During the period that qualifies me for loan forgiveness, I taught (check only one box): Full time in an elementary school as a highly qualified special education teacher for children with disabilities. The children’s disabilities corresponded to my special education training, and I demonstrated knowledge and teaching skills in the content areas of the elementary or secondary school curriculum (loan forgiveness of up to $17,500). Full time in a secondary school as a highly qualified special education teacher for children with disabilities. The children’s disabilities corresponded to my special education training, and I demonstrated knowledge and teaching skills in the content areas of the elementary or secondary school curriculum (loan forgiveness of up to $17,500). Full time in a secondary school as a highly qualified mathematics teacher (loan forgiveness of up to $17,500). Full time in a secondary school as a highly qualified science teacher (loan forgiveness of up to $17,500). Full time in a secondary school (i) in a subject area relevant to my academic major, or (ii) as a highly qualified secondary school teacher (loan forgiveness of up to $5,000). Full time in an elementary school (i) where I demonstrated knowledge and teaching skills in reading, writing, mathematics, and other areas of the elementary school curriculum, or (ii) as a highly qualified elementary school teacher (loan forgiveness of up to $5,000). Previous Loan Forgiveness Information Check one of the boxes below: I have not previously applied for or received forgiveness on my FFEL and/or Direct Loan program loan(s) under this Teacher Loan Forgiveness Program. I have applied for or received forgiveness on my FFEL and/or Direct Loan program loan(s) under this Teacher Loan Forgiveness Program with the loan holder listed below. (If you check this box, provide the loan holder and forgiveness amount information requested below. If you have applied for but have not yet received forgiveness, leave "Forgiveness Amount" blank.) |
||||||||||||||||||||||||||||||||||
|
Loan Holder Name |
|
|
Loan Holder Telephone/Web Site |
|
|
Forgiveness Amount |
$ |
||||||||||||||||||||||||||
Understandings and Certification I understand that a forbearance of principal and accrued interest will be applied on the qualifying loan(s) from the date my loan holder receives my completed loan forgiveness application through the date the loan forgiveness request is approved or denied, unless I notify my loan holder that I intend to make regular payments during this period. However, making regular payments may reduce the amount of my loan forgiveness. I understand that any unpaid interest that accrues during the forbearance may be capitalized. I certify that: (1) The information I provided in Sections 1 and 2 is true and correct; (2) I have read and understand the terms and conditions in Section 5 and the definitions in Sections 6 and 7; and (3) I meet eligibility requirements for teacher loan forgiveness as explained in Section 8. |
||||||||||||||||||||||||||||||||||
Borrower’s Signature |
|
|
Date |
|
||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||
SECTION 3: CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION |
The Chief Administrative Officer, such as principal, assistant principal, or superintendent, must complete this section. |
|||||||||||||||||||||||||||||||||
Before completing this section, carefully read the general information and instructions, definitions, and eligibility requirements in Sections 4, 6, 7, and 8. More than one Chief Administrative Officer's certification may be required. Return the completed form to the borrower. I certify, to the best of my knowledge and belief, that the borrower has met the teaching service requirements for loan forgiveness as specified in Sections 6, 7, and 8. In addition, I certify that, during the period for which the borrower is seeking forgiveness, the borrower was a teacher as defined in Section 6 and taught full time for consecutive, complete academic year(s) from _________________________(mm-dd-yyyy) to ________________________(mm-dd-yyyy) at an eligible Title I school(s) in the capacity that the borrower has indicated in Section 2. |
||||||||||||||||||||||||||||||||||
|
Check here if this school is operated by the Bureau of Indian Education (BIE) or operated on an Indian reservation by an Indian tribal group under contract with the BIE. |
|||||||||||||||||||||||||||||||||
School Name (Not School District) |
||||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||
School Address (Street, City, State, Zip Code) |
|
County |
||||||||||||||||||||||||||||||||
|
|
( ) |
||||||||||||||||||||||||||||||||
Chief Administrative Officer’s Name and Title (Printed) |
|
Telephone |
||||||||||||||||||||||||||||||||
|
|
|
||||||||||||||||||||||||||||||||
Chief Administrative Officer’s Signature |
|
Today’s Date |
SECTION 4: GENERAL INFORMATION AND INSTRUCTIONS |
|
SECTION 5: TERMS AND CONDITIONS |
|
SECTION 6: DEFINITIONS |
Half years exclude summer sessions. Two half years generally fall within a 12-month period. For schools that have a year-round program of instruction, a minimum of nine months is considered an academic year.
|
SECTION 7: DEFINITION OF HIGHLY QUALIFIED |
Public and private school teachers may meet different criteria in order to be considered “highly qualified” for the purposes of the Teacher Loan Forgiveness Program, as explained below. Public School Teachers
In addition:
1. Holds at least a bachelor’s degree; and 2. Has demonstrated, by passing a rigorous state test, subject knowledge and teaching skills in reading, writing, mathematics, and other areas of the basic elementary school curriculum (which may consist of passing a state-required certification or licensing test or tests in reading, writing, mathematics, and other areas of the basic elementary school curriculum).
1. Holds at least a bachelor’s degree; and 2. Has demonstrated a high level of competency in each of the academic subjects in which the teacher teaches by: (a) Passing a rigorous state academic subject test in each of the academic subjects in which the teacher teaches (which may consist of a passing level of performance on a state-required certification or licensing test or tests in each of the academic subjects in which the teacher teaches); or (b) Successful completion, in each of the academic subjects in which the teacher teaches, of an academic major, a graduate degree, coursework equivalent to an undergraduate academic major, or advanced certification or credentialing.
1. Meets the applicable standards of an elementary, middle, or secondary school teacher who is new to the profession; or 2. Demonstrates competence in all the academic subjects in which the teacher teaches based on a high objective, uniform state standard of evaluation that: (a) Is set by the state for both grade appropriate academic subject matter knowledge and teaching skills; (b) Is aligned with challenging state academic content and student academic achievement standards and developed in consultation with core content specialists, teachers, principals, and school administrators; (c) Provides objective, coherent information about the teacher’s attainment of core content knowledge in the academic subjects in which a teacher teaches; (d) Is applied uniformly to all teachers in the same academic subject and the same grade level throughout the state; (e) Takes into consideration, but is not based primarily on, the time the teacher has been teaching in the academic subject; (f) Is made available to the public upon request; and (g) May involve multiple, objective measures of teacher competency. Private School Teachers
|
SECTION 8: ELIGIBILITY REQUIREMENTS |
Note: All elementary and secondary schools operated by the Bureau of Indian Education (BIE) or operated on Indian reservations by Indian tribal groups under contract with the BIE qualify as schools serving low-income students. These schools are qualifying schools for purposes of this loan forgiveness program.
|
SECTION 8: ELIGIBILITY REQUIREMENTS (continued) |
|
1. A full-time elementary school teacher who demonstrated knowledge and teaching skills in reading, writing, mathematics, and other areas of the elementary school curriculum; or 2. A full-time secondary school teacher who taught in a subject area that was relevant to your academic major.
1. A highly qualified full-time mathematics or science teacher in an eligible secondary school; or 2. A highly qualified special education teacher whose primary responsibility was to provide special education to children with disabilities, and you taught children with disabilities that corresponded to your area of special education training and have demonstrated knowledge and teaching skills in the content areas of the curriculum that you taught.
1. A highly qualified full-time mathematics or science teacher in an eligible secondary school; or 2. A highly qualified special education teacher whose primary responsibility was to provide special education to children with disabilities, and you taught children with disabilities that corresponded to your area of special education training and have demonstrated knowledge and teaching skills in the content areas of the curriculum that you taught.
1. You returned to postsecondary education, on at least a half-time basis, in an area of study directly related to the performance of the teaching service described above; or 2. You had a condition covered under the Family and Medical Leave Act of 1993 (FMLA); or 3. You were called or ordered to active duty status for more than 30 days as a member of a reserve component of the Armed Forces. Note: Absence due to a period of postsecondary education, a condition covered under the FMLA, or active duty service, including the time needed for you to resume teaching no later than the beginning of the next regularly scheduled academic year, does not constitute a break in the required five consecutive, complete years of qualifying teaching service. |
|
SECTION 9: WHERE TO SEND THE COMPLETED TEACHER LOAN FORGIVENESS APPLICATION |
|
Return the completed form and any attachments to: (If no address is shown, return to your loan holder.)
|
If you need help completing this form, call: (If no phone number is shown, call your loan holder.) |
SECTION 9: IMPORTANT NOTICES |
|
Privacy Act Disclosure Notice: The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you: The authorities for collecting the requested information from and about you are 428(b)(2)(A) et seq. and 451 et seq. of the Higher Education Act of 1965, as amended (20 U.S.C. 1078(b)(2)(A) et seq. and 20 U.S.C. 1087a et seq.) and the authority for collecting and using your Social Security Number (SSN) is 484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)). Participating in the Federal Family Education Loan (FFEL) Program or the William D. Ford Federal Direct Loan (Direct Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate. The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the FFEL Program and/or Direct Loan Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect on your loan(s) if your loan(s) becomes delinquent or in default. We also use your SSN as an account identifier and to permit you to access your account information electronically. The information in your file may be disclosed to third parties as authorized under routine uses in the appropriate systems of records. The routine uses of this information include its disclosure to federal, state, or local agencies, to other federal agencies under computer matching programs, to agencies that we authorize to assist us in administering our loan programs, to private parties such as relatives, present and former employers, business and personal associates, to credit bureau organizations, to financial and educational institutions, to guaranty agencies, and to contractors in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to counsel you in repayment efforts, to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student financial aid program regulations, to locate you if you become delinquent in your loan payments or if you default, to provide default rate calculations, to provide financial aid history information, to assist program administrators with tracking refunds and cancellations, or to provide a standardized method for educational institutions efficiently to submit student enrollment status. In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may also be made to qualified researchers under Privacy Act safeguards.Paperwork Reduction Notice: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0059. The time required to complete this information collection is estimated to average 0.33 hours (20 minutes) per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4700. If you have questions regarding the status of your submission of this form, contact your loan holder (see Section 9). |
Page
File Type | application/msword |
File Title | ED SEAL |
Author | Don E. Watson |
Last Modified By | Sheila.Carey |
File Modified | 2008-02-06 |
File Created | 2008-02-06 |