TQE Scholarship Form Addendum

OMB No. 1840-0753

Expiration Date: XX/XX/XXXX

TEACHER QUALITY ENHANCEMENT PROGRAMS

TITLE II, HIGHER EDUCATION ACT (HEA)

SCHOLARSHIP TERMS AND CONDITIONS ADDENDUM

SECTION I: RECIPIENT SECTION

Name (last, first, middle initial):

Permanent Address (street, city, state, zip code):

Date of Birth:

Area Code/Phone Number:

Cell Phone Number:

E-Mail Address:

Social Security Number:

SECTION II: INSTITUTION SECTION

Part A

Name of Institution:

Address (street, city, state, zip code):

Institution’s DUNS Number:

Name of Contact (last, first, middle initial):

Area Code/Phone Number of Institution Contact:

E-mail Address of Institution Contact:

Part B

Amount of Title II, HEA Funds Awarded as Scholarship:

Period of Scholarship:

Recipient Enrolled as Percentage of Full-Time Equivalent Student:

ED Grant Award Number:

Scholarship Award Date:

SECTION III: TERMS AND CONDITIONS

All of the terms and conditions that govern the receipt of a Teacher Quality Enhancement Program scholarship for the period noted on the cover of this document are spelled out in the complete scholarship agreement that you read and signed before your first term in the scholarship program. At that time, you were given an additional copy of them for your files. By signing this addendum, you acknowledge that you still understand the terms and conditions and still agree to abide by them. A copy of the complete terms and conditions of the scholarship agreement is available for your review before you sign this addendum.

NOTE: Should you not meet your service obligation, the interest rate that applies to repayment of all scholarship support will be “the prevailing rate [established by the U.S. Treasury] at the time a repayment schedule is established.” If the terms and conditions of your initial scholarship agreement established a five percent rate of interest on the amount of scholarship you received for that term, you will be able to have the prevailing rate of interest at the time a repayment schedule is established apply to scholarship funds you received for that initial term if the prevailing rate of interest is lower than five percent.

My signature certifies that I have read, understand, and agree to the terms and conditions of this scholarship agreement.

____________________________________ __________________

Scholarship Recipient’s Signature Date:

____________________________________

Name of Scholarship Recipient:

_____________________________________ ___________________

Authorized Institutional Official Signature Date:

_____________________________________ ___________________

Name of Official: Title:

Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority for collecting the requested information from and about you is Title II, Section 204(e) of the Higher Education Act of 1965, as amended by the 1998 Higher Education Amendments, and 31 U.S.C. Chapter 37. We request your Social Security Number (SSN) under this authority in order to accurately track your records and to differentiate your teaching and financial obligation from other program participants who may have the same name as you. You are advised that your participation in the Teacher Quality Enhancement Grants scholarship program is voluntary and that giving us your SSN is voluntary, but you must provide the requested information, including your SSN, to participate. The information will be used to ensure that recipients of scholarships provided with funds under Title II of the Higher Education Act subsequently: (1) complete a teacher education program and teach in a high-need school of a high-need local educational agency for a period of time equivalent to the period for which the recipient received scholarship assistance; or (2) repay the amount of the scholarship. The information in your records may be disclosed to third parties as authorized under routine uses in the appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the computer matching requirements of the Privacy Act, under a computer matching agreement.

The routine uses of this information include sending the information, in the event of litigation, to the Department of Justice (DOJ), 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 also send this information to law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or collect on the debt. We may send information to members of Congress if you ask them to help you with questions related to this Program. 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. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us determine whether the Freedom of Information Act requires the disclosure of particular records. We can disclose records to contractors if we contract with an entity to perform functions that require the disclosure of the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act. You must provide all of the information requested in order to have your request for tuition reimbursement processed.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit. The authority for collecting the requested information from and about you is Title II, Section 204(e) of the Higher Education Act of 1965, as amended by the 1998 Higher Education Amendments, and 31 U.S.C. Chapter 37. We request your Social Security Number (SSN) under this authority in order to accurately track your records and to differentiate your teaching and financial obligation from other program participants who may have the same name as you. You are advised that your participation in the Teacher Quality Enhancement Grants scholarship program is voluntary and that giving us your SSN is voluntary, but you must provide the requested information, including your SSN, to participate.

Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or e-mail [email protected] and reference the OMB Control Number 1840-0753. Note: Please do not return the completed Scholarship Terms And Conditions Addendum to this address.

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