Paul Douglas Teacher Scholarship Program

	PAUL DOUGLAS TEACHER SCHOLARSHIP PROGRAM
	PERFORMANCE REPORT FOR FY 20XX
	Reporting Period: July 1, 20XX - June 30, 20XX
	STATE:
	PLEASE READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM
	Section I: Summary Repayment Information				Section II: Fulfillment of Scholarship Obligation
	A.	Number of Recipients as of June 30, 20XX:				Number of Recipients as of June 30, 20XX who have
	1.	In repayment status			A.	Completed the teacher
	2.	In default status				certification course of study:
	3.	In deferment status
	4.	Total - Cumulative	0		B.	Taught by grade level:	Public-A		Private-B
					1.	Preschool level
	B.	Not in repayment status & not teaching:			2.	Elementary level
	1.	Still pursuing course of study			3.	Secondary level
		leading to teacher certification			4.	Total - Cumulative	0		0
	2.	No longer pursuing teacher
		certification course of study			C.	Taught in teacher shortage area:
	3.	Certified to teach but not yet			1.	Geographic
		teaching (grace period)			2.	Grade level
	4.	Total - Cumulative	0		3.	Subject matter
					4.	Total - Cumulative	0
	C.	Amount repaid during FY 20XX:
	1.	Principal			D.	Completed the Scholarship obligation:
	2.	Interest			1.	By teaching
	3.	Total	$0		2.	By repaying the Scholarship
					3.	By teaching & repayment
	D.	Amount of principal as of June 30, 20XX:			4.	Total - Cumulative	0
	1.	Total outstanding
	2.	In default status			E.	Had the Scholarship obligation
	3.	In deferment status				cancelled:
	E.	Amount of uncollectible debt written			Section III: Summary Outcomes for All Former Scholars
		off as of June 30, 20XX:
	1.	Principal written-off			A.	Not in repayment status and not teaching	0
	2.	Interest written-off			B.	Teaching	0
	3.	Total - Cumulative	$0		C.	In repayment status	0
	4.	Number of Scholarships written-off			D.	Completed or cancelled obligation	0
					E.	Written-Off	0
					F.	Total - Cumulative	0
	Section IV: Certification by Authorized Official
	I certify that the information provided in this Performance Report is based upon information reflected in the official accounting and program records of this agency. Upon request, such records will be made available to the Secretary or his/her delegate for review.
	SIGNATURE					DATE
	TYPED NAME/TITLE OF AUTHORIZED OFFICIAL
	TELEPHONE NUMBER (AREA CODE) AND EXTENSION
	FAX NUMBER (AREA CODE)					E-MAIL ADDRESS
	NAME OF STATE AGENCY
						ED Form Number(s): 40-31P, 84.176
	STREET ADDRESS
						OMB NUMBER: 1840-0787
	STREET ADDRESS
						Expiration Date: XX/XX/2021
	CITY/STATE/ZIP CODE
	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 12 hours 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 benefit under Title V, Part C, Subpart 1 of the Higher Education Act of 1965, as amended (20 U.S.C. 1104 through 1104K). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to regulations.gov during the public comment period for this collection of information. If you have specific questions about the form, instrument or survey, please contact the U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, DC 20202-4536.