1845-0158_TEACH FMLA Susp_30D_2023-09-12

TEACH GRANT SERVICE OBLIGATION SUSPENSION REQUEST:
FAMILY AND MEDICAL LEAVE ACT (FMLA) CONDITION

OMB No. 1845-0158
Form Under Review
Exp. Date XX/XX/XXXX

Teacher Education Assistance for College and Higher Education (TEACH) Grant Program
FMLA

WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document is subject to
penalties that may include fines, imprisonment, or both, under the U.S. Criminal Code and 20 U.S.C. 1097.
GENERAL INFORMATION AND INSTRUCTIONS
NOTE: Throughout this form, the words “we,” “us,” and “our” refer to the U.S. Department of Education or to your TEACH Grant servicer, acting on
behalf of the U.S. Department of Education. The word “Agreement” refers to the Agreement to Serve or Repay that you signed before you received
your TEACH Grants.
How do I use this form?
As explained in your Agreement, you can request a suspension of the 8-year period for completing your TEACH Grant service obligation if you are
temporarily unable to teach due to certain qualifying conditions. You may use this form to request a suspension of the 8-year period for completing
your service obligation if you are temporarily unable to teach because you have a condition that is a qualifying reason for leave under the Family
and Medical Leave Act (FMLA). See Section 4 of the form for specific eligibility requirements.
How do I complete the form?
•

Before you begin, carefully read the entire form. Be sure to provide all requested information. Type or print using dark ink.

•

Your name, address, and other information may be preprinted in Section 1. If any of this information is not shown, or if any of the preprinted
information is incorrect, enter or correct the information on the right side of Section 1. If any of your information has changed since the last
time you reported it to us, check the box in Section 1 to indicate this.

•

Check the box in Section 2 that describes your qualifying reason for leave under the FMLA and provide any additional requested information
for the box that you check. Enter dates as month-day-year. For example, you would enter “August 25, 2024” as “0 8 - 2 5 - 20 2 4”.

•

Complete Section 3:

•

o

Enter the beginning and ending dates (month and year only) of the school year for which you are requesting a suspension of the 8-year
service obligation period. For example, if you are requesting a suspension to cover a school year that begins in August 2024 and ends in
June 2025, you would enter “0 8 - 20 2 4” as the beginning date and “0 6 - 20 2 5” as the ending date.

o

Sign and date the form in Section 3. Enter the date as month-day-year. For example, if you signed the form on August 25, 2024, you
would enter “0 8 - 2 5 - 20 2 4”.

Make sure that all sections are complete, then send us the completed form by one of the following means:
o

Mail the form and any required documentation to the following address:
U.S. Department of Education
MOHELA
633 Spirit Drive
Chesterfield, MO 63005-1243

o

Fax the form to 1-866-222-7060.

o

Upload the form online atmohela.com/uploadDocument.

Who can I contact if I have questions?
The U.S. Department of Education uses a servicer to monitor your progress toward completing your TEACH Grant service obligation, and to answer
any questions you may have about your service obligation. If you change your address, email address, or telephone number, it is very important to
make sure that your TEACH Grant servicer has your current contact information. If you need help completing this form, or if you have questions
about the status of your certification after you have submitted the form, contact your TEACH Grant servicer:
MOHELA
1-888-866-4352
International: 636-532-0600
mohela.com

Page 1 of 4 30D DRAFT 09/12/2023

TEACH GRANT SERVICE OBLIGATION SUSPENSION REQUEST:
FAMILY AND MEDICAL LEAVE ACT (FMLA) CONDITION
SECTION 1: GRANT RECIPIENT INFORMATION
See the instructions on page 1.
SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Name
___________________________________________________
Address ___________________________________________________
City, State, Zip _______________________________________________
Telephone – Primary
( _______ ) _______ - _________________
Telephone – Alternate
( _______ ) _______ - _________________
Email (optional)
___________________________________________
Check this box if you are changing any preprinted information.

SECTION 2: DOCUMENTATION OF YOUR QUALIFYING REASON FOR LEAVE UNDER THE FMLA
Check the box that describes the condition that would qualify you for leave under the FMLA and provide the requested information.
CHECK ONLY ONE BOX.
I am/was caring for my newborn child who was born on ___ ___ - ___ ___ - 20 ___ ___.
I am/was caring for my newly adopted child or foster child who was placed in my home on ___ ___ - ___ ___ - 20 ___ ___.
I am/was caring for my (check one)
on ___ ___ - ___ ___ - 20 ___ ___.

spouse

child or

parent with a serious health condition, and I began caring for this individual

I have/had a serious health condition that makes/made me unable to perform the functions of my job, and this condition affected my ability to
work beginning on ___ ___ - ___ ___ - 20 ___ ___.
I am/was caring for my (check one)
spouse
child
parent or
next-of-kin who is a covered service member with a serious injury or
illness, and I began caring for this individual on ___ ___ - ___ ___ - 20 ___ ___.
I have/had a qualifying military exigency resulting from the fact that my spouse, child, or parent is a covered military member on active duty in
support of a contingency operation, or has been notified of an impending call or order to active duty in support of a contingency operation
(contact your TEACH Grant servicer for more information about this condition).
SECTION 3: YOUR SUSPENSION REQUEST, UNDERSTANDINGS, AND CERTIFICATIONS
I request that the U.S. Department of Education (ED) grant a temporary suspension of the period for completing my TEACH Grant service obligation
during the full elementary or secondary school year beginning ___ ___ - 20 ___ ___ and ending ___ ___ - 20 ___ ___. I am/was unable to complete
a full year of teaching service during this school year for the reason I indicated in Section 2.
I understand that:
1.

If I qualify for a suspension, I will receive a suspension for a consecutive 12-month period. If I continue to qualify for a suspension at the end of
one suspension period, I may reapply for another 12-month suspension. There is a maximum limit on the period of time for which the 8-year
period for completing my TEACH Grant service obligation may be suspended, as explained in Section 4 of this form.

2.

My TEACH Grant servicer must receive my suspension request before my TEACH Grants are converted to Direct Unsubsidized Loans. As
explained in my Agreement, my TEACH Grants will be converted to Direct Unsubsidized Loans if I do not begin teaching or do not continue to
perform qualifying teaching service within a timeframe that would allow me to complete my required 4 years of teaching within my 8-year
service obligation period.

3.

ED will not approve my suspension request unless this form is complete and I have provided any required documentation.

I certify that: (1) the information I have provided on this form is true and correct; (2) I have read, understand, and meet the eligibility requirements
of the suspension that I have requested, as explained in Sections 2 and 4; and (3) upon request, I will provide additional documentation to my
TEACH Grant servicer to support my suspension request.
Grant Recipient’s Signature ___________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

Page 2 of 4
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

SECTION 4: SUSPENSION ELIGIBILITY REQUIREMENTS AND MAXIMUM SUSPENSION PERIOD
Suspension eligibility requirements
You may qualify for a temporary suspension of the 8-year period for completing your TEACH Grant service obligation if you are temporarily unable
to teach because you have a condition that is a qualifying reason for leave under the Family and Medical Leave Act (FMLA).
Note: To qualify for a suspension based on a qualifying reason for leave under the FMLA, you are not required to be granted leave under the FMLA.
You must simply have a condition that would make you eligible for FMLA leave.
Qualifying reasons for leave under the FMLA are:
•

Caring for your newborn child;

•

Caring for your newly adopted child or a foster child who was placed in your home;

•

Caring for your spouse, child, or parent with a serious health condition;

•

A serious health condition that makes you unable to perform the functions of your job;

•

Caring for a covered service member with a serious injury or illness; or

•

A qualifying military exigency resulting from the fact that your spouse, child, or parent is a covered military member on active duty (or
has been notified of an impending call or order to active duty) in support of a contingency operation.

For more detailed information about qualifying reasons for leave under the FMLA, visit https://www.dol.gov/agencies/whd/fmla.
If you qualify for a suspension, your TEACH Grant servicer must receive your suspension request before your TEACH Grants are converted to Direct
Unsubsidized Loans. Refer to your Agreement or contact us (see "Who can I contact if I have questions?" on page 1) for more information about
the conditions under which your TEACH Grants may be converted to loans.
Maximum suspension period
If you meet the requirements described in this section, you will receive a temporary suspension of the 8-year period for completing your TEACH
Grant service obligation for a consecutive 12-month period covering the school year during which you are temporarily unable to teach. If you
continue to qualify for a suspension at the end of one suspension period, you may reapply for another 12-month suspension. However, there is a
maximum 3-year limit on the period of time for which you may receive a suspension of the 8-year service obligation period based on having a
condition that is a qualifying reason for leave under the FMLA, in combination with any periods of suspension you may receive based on certain
other conditions, as explained in your Agreement.

Page 3 of 4
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

SECTION 5: IMPORTANT NOTICES
PRIVACY ACT NOTICE

its disclosure to federal, state, or local agencies, to private parties such
as relatives, present and former employers, business and personal
The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice
associates, to creditors, to financial and educational institutions, and to
be provided to you:
guaranty agencies to verify your identity, to determine your program
The authorities for collecting the requested information from and about eligibility and benefits, to permit making, servicing, assigning, collecting,
you are §420L et seq. and §451 et seq. of the Higher Education Act (HEA) adjusting or discharging your loan(s), to enforce the terms of the loan(s),
of 1965, as amended (20 U.S.C. 1070g et seq. and 20 U.S.C. 1087a et
to investigate possible fraud and to verify compliance with federal
seq.) and the authorities for collecting and using your social security
student financial aid program regulations, to locate you if you become
number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and
delinquent in your loan payments or if you default, or to verify whether
§31001(i)(1) of the Debt Collection Improvement Act of 1996 (31 U.S.C. your debt qualifies for discharge or cancellation. To provide default rate
7701(c)). Participating in the Teacher Education Assistance for College
calculations, disclosures may be made to guaranty agencies, to financial
and Higher Education (TEACH) Grant Program and/or the William D.
and educational institutions, or to federal, state or local agencies. To
Ford Federal Direct Loan (Direct Loan) Program and giving us your SSN
provide financial aid history information, disclosures may be made to
are voluntary, but you must provide the requested information,
educational institutions. To assist program administrators with tracking
including your SSN, to participate.
refunds and cancellations, disclosures may be made to guaranty
agencies, to financial and educational institutions, or to federal or state
The principal purposes for collecting the information on this form,
agencies.
including your SSN, are to verify your identity, to determine your
eligibility to receive a TEACH Grant, and, if a TEACH Grant that you
To provide a standardized method for educational institutions to
receive is converted to a Direct Unsubsidized Loan, to determine
efficiently submit student enrollment status, disclosures may be made
your eligibility to receive a benefit on the loan (such as deferment,
to guaranty agencies or to financial and educational institutions. To
forbearance, discharge, or forgiveness), to permit the servicing of
counsel you in repayment efforts, disclosures may be made to guaranty
your loan(s), and, if it becomes necessary, to locate you and to
agencies, to financial and educational institutions, or to federal, state, or
collect and report on your loan(s) if your loan(s) become delinquent
local agencies.
or in default. We also use your SSN as an account identifier and to
PAPERWORK REDUCTION NOTICE
permit you to access your account information electronically.
According to the Paperwork Reduction Act of 1995, no persons are
The information in your file may be disclosed, on a case-by-case basis or
required to respond to a collection of information unless it displays a
under a computer matching program, to third parties as authorized
currently valid OMB control number. The valid OMB control number for
under routine uses in the appropriate systems of records notices.
this information collection is 1845-0158. Public reporting burden for this
The routine uses of the information that we collect about you, if your
collection of information is estimated to average 20 minutes (0.33
TEACH Grant has not been converted to a Direct Unsubsidized Loan,
hours) per response, including time for reviewing instructions, searching
include, but are not limited to, its disclosure to federal, state, or local
existing data resources, gathering and maintaining the data needed, and
agencies, to institutions of higher education, and to third party servicers completing and reviewing the collection of information. The obligation
to determine your eligibility to receive a TEACH Grant, to investigate
to respond to this collection is required to obtain a benefit in
possible fraud, and to verify compliance with federal student financial
accordance with 34 CFR 686.41(b).
aid program regulations.
If you have comments or concerns regarding the status of your
In the event of litigation, we may send records to the Department of
individual submission of this form, write to:
Justice, a court, adjudicative body, counsel, party, or witness if the
U.S. Department of Education
disclosure is relevant and necessary to the litigation. If this information,
MOHELA
either alone or with other information, indicates a potential violation of
633 Spirit Drive
law, we may send it to the appropriate authority for action. We may
Chesterfield, MO 63005-1243
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 be made to our contractors for the purpose of
performing any programmatic function that requires disclosure of
records. Before making any such disclosure, we will require the
contractor to maintain Privacy Act safeguards. Disclosures may also be
made to qualified researchers under Privacy Act safeguards.
If your TEACH Grant has been converted to a Direct Unsubsidized Loan,
the routine uses of this information also include, but are not limited to,
Page 4 of 4
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600