1845-0158_TEACH Cert_REV FINAL FOR OMB_2020-09-18

CRT

TEACH GRANT CERTIFICATION OF QUALIFYING TEACHING

Teacher Education Assistance for College and Higher Education (TEACH) Grant Program
REVISED FINAL FOR OMB APPROVAL 2020-09-18

OMB No. 1845-0158

Form Approved

Exp. Date xx/xx/xxxx

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. The word “Agreement” refers to the Agreement to Serve or Repay that you signed before you received each of your TEACH Grants.

How do I use this form?

As explained in your Agreement, you must complete at least 4 elementary or secondary school years of qualifying teaching service for each program of study for which you received a TEACH Grant. You must provide us with documentation of each completed year of teaching by submitting this form.

As further explained in your Agreement, if you do not begin or do not maintain qualifying teaching service within a timeframe that would allow you to complete your required 4 years of teaching within the 8-year period described in your Agreement, the TEACH Grants you received will be converted to Direct Unsubsidized Loans that you must repay in full. Upon our request, you must document that you have begun qualifying teaching service by submitting this form.

How do I complete the form?

• Before you begin, carefully read the entire form. 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 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.

• Complete Section 2. Be sure to answer all questions.

• 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, 2021, you would enter “0 8 - 2 5 - 20 2 1”).

• Enter your name and Social Security Number (SSN) at the top of page 3, then have the chief administrative officer (CAO) of your school or educational service agency complete Section 4. If you are certifying a completed year of teaching and you met the requirements for a full school year of teaching by teaching at different schools or for different educational service agencies during the same school year, the CAO for each school or educational service agency must complete Section 4. If you need a certification from more than one CAO, an additional copy of Section 4 is included on page 7 of this form. Be sure to enter your name and SSN at the top of each certification page that you submit. If the same CAO is authorized to certify your teaching during the same academic year at different schools or for different educational service agencies (for example, if you taught at different schools within the same school district), the CAO must provide the information requested in Section 4 for each school or educational service agency.

• Make sure that all sections are complete, then send us the completed form (including any additional CAO certifications if required) by one of the following means:

  • Mail the form and any required documentation to the following address:

U.S. Department of Education
FedLoan Servicing
P.O. Box 69184
Harrisburg, PA 17106-9184

• Fax the form to 717-720-1628.

• Upload the form via Account Access at myfedloan.org.

Who can I contact if I have questions?

The U.S. Department of Education uses a servicer (FedLoan Servicing) 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:

FedLoan Servicing
1-800-699-2908

International: 717-720-1985

myfedloan.org

TEACH GRANT CERTIFICATION OF COMPLETED TEACHING

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: INFORMATION ABOUT YOUR TEACHING SERVICE (TO BE COMPLETED BY THE TEACH GRANT RECIPIENT)

Read the definitions in Section 6 before you complete this section.

1. Did you complete a full school year of teaching or have you begun teaching?

Yes – Continue to Question 2.

No – Do not complete this form; you must have completed a full school year of teaching or must have begun teaching.

2. Were you a full-time teacher or have you begun full-time teaching?

Yes – Continue to Question 3.

No – Do not complete this form; you must teach full-time.

3. Did you teach or have you begun teaching at a low-income school, as defined in Section 6 of this form?

Yes – Continue to Question 4.

No – Do not complete this form; you must teach at a low-income school as defined in Section 6.

4. Did you teach or have you begun teaching more than half of your classes in a high-need field, as defined in Section 6 of this form?

Yes – Continue to Question 5.

No – Do not complete this form; you must teach the majority of your classes in a high-need field as defined in Section 6.

5. Where did you teach or where have you begun teaching? Check all that apply.

at a low-income elementary school

at a low-income secondary school

for a low-income educational service agency (ESA)

6. In what high-need field or fields did you teach or have you begun teaching? Check all that apply.

Bilingual education or English language acquisition Foreign language Math

Reading specialist Science (includes computer science) Special education

Other high-need field not listed above (see the definition of “high-need field” in Section 6). If you check this box, continue to Question 7. Otherwise, go to Section 3.

7. If you checked “other high-need field not listed above” in Question 6, in what other high-need field did you teach or have you begun teaching? IMPORTANT: You must identify the other high-need field using the same name under which the field is listed in the Nationwide List (see the definition of “high-need field” in Section 6).

________________________________________________________________________________________________________________

SECTION 3: YOUR CERTIFICATIONS AND UNDERSTANDINGS (TO BE COMPLETED BY THE TEACH GRANT RECIPIENT)

I certify that (1) the information I have provided on this form is true and correct; (2) I have read and understand the terms and conditions and definitions in Sections 5 and 6; and (3) upon request, I will provide additional documentation to my TEACH Grant servicer to document my qualifying teaching service.

IMPORTANT: I understand that (1) under the terms and conditions of my Agreement, any TEACH Grant I received for a program of study will be converted to a Direct Unsubsidized Loan if I do not begin qualifying teaching or continue to perform qualifying teaching service within a timeframe that would allow me to complete my required 4 years of teaching within the 8-year period required by my Agreement; and (2) if any TEACH Grant that I received is converted to a Direct Unsubsidized Loan, I must repay that loan in full, with interest charged from the date of each TEACH Grant disbursement.

Grant Recipient’s Signature _________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

Grant Recipient’s Name _______________________________________________________________ SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Grant Recipient’s Name _______________________________________________________________ SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___

SECTION 4: CHIEF ADMINISTRATIVE OFFICER’S (CAO’S) CERTIFICATION

Read the definitions in Section 6 before completing this section. Be sure to sign and date the form at the bottom of this page. Return the form to the grant recipient.

1. What is the name of the school or educational service agency (ESA) where the grant recipient taught or is currently teaching? Enter the name and other information requested below, then continue to Question 2.

Note: If the grant recipient met the requirements for a full school year of teaching by teaching at different schools or for different ESAs and you are authorized to certify the recipient’s teaching service at each school or ESA (for example, if the recipient taught at different schools within the same school district), provide all information requested below for each school or ESA. Attach additional pages if necessary; include all information requested in this section.

School (not school district) or ESA Name __________________________________________________________________________________

Check here if this is a school or ESA 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 or ESA Address (Street, City, State, Zip Code) ____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

School or ESA Website _________________________________________________________________________________________________

School District ___________________________________________________________________________ County ______________________

2. Was/is the grant recipient a full-time, highly-qualified teacher during the school year(s) of teaching that you are being asked to certify?

Yes – Continue to Question 3.

No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.

3. Were/are more than half of the classes that the grant recipient taught/teaches in the high-need field(s) indicated by the grant recipient in Section 2?

Yes – Continue to Question 4.

No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.

4. Has the grant recipient met his or her contractual requirements (for purposes of salary increases, tenure, and retirement) for a full school year of teaching, and has that school year ended?

Yes – Continue to Question 5.

No – Skip to Question 8.

5. Check the box below that describes how the grant recipient completed a full school year of teaching, then follow the instructions for the box that you check. Check only one box.

The grant recipient completed a full school year of teaching during one school year at the same school or for the same ESA. Continue to Question 6 and identify the school year.

The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years within the same school year at different schools or for different ESAs. Continue to Question 6 and identify the school year.

The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years of teaching during different school years at either the same school or for the same ESA or at different schools or for different ESAs. Skip to Question 7 and identify the school year.

6. The grant recipient taught for the full 20___ ___ – 20___ ___ school year.

7. The grant recipient taught for the second half of the 20___ ___ – 20___ ___ school year and for first half of the 20___ ___ – 20___ ___ school year.

8. The grant recipient has begun teaching for the 20___ ___ school year, but has not yet completed a full school year of teaching.

I certify that the information I have provided above about the TEACH Grant recipient’s teaching service is true and correct.

CAO’s Name _____________________________________________________________________________________________________________

CAO’S Title (printed) ______________________________________________________________________________________________________

Telephone ( _______ ) _______ - _____________ Email _________________________________________________________________________

CAO’s Signature ____________________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

SECTION 5: TERMS AND CONDITIONS OF YOUR TEACH GRANT SERVICE OBLIGATION

For each program of study for which you received a TEACH Grant, you must complete a service obligation by teaching full-time for a total of at least 4 elementary or secondary school years (1) as a highly-qualified teacher; (2) at a school or educational service agency serving low-income students; and (3) in a high-need field.

You must complete the 4 years of teaching within 8 years after you cease to be enrolled at the postsecondary institution where you received your TEACH Grants. You must provide us with documentation of each completed school year of teaching. When requested, you must provide us with other documentation showing that you are meeting the terms and conditions of your service obligation.

If you do not begin qualifying teaching or continue to perform qualifying teaching service within a timeframe that would allow you to complete the required 4-year service obligation for a program of study within the 8-year period required by your Agreement, any TEACH Grant you received for that program of study will be converted to a Direct Unsubsidized Loan that you must repay in full, with interest charged from the date of each TEACH Grant disbursement you received. Any TEACH Grant you received will also be converted to a Direct Unsubsidized Loan if you ask us to convert your TEACH Grant to a loan because you have decided not to teach in an eligible school or field, or for any other reason. For the complete terms and conditions of your TEACH Grant service obligation, refer to your Agreement.

SECTION 6: DEFINITIONS

Chief administrative officer

The chief administrative officer (CAO) who may complete Section 4 is the official who has access to employment records that establish that your teaching service meets the terms and conditions of your TEACH Grant Agreement, as described in Section 5, and who is authorized to verify your qualifying teaching service. Depending on your employer, the chief administrative officer may be a superintendent, a human resources official or other school district or educational service agency official, or a principal or assistant principal.

Educational service agency

An educational service agency (ESA) is a regional, public multiservice agency (not a private organization) authorized by state statute to develop, manage, and provide services or programs to local educational agencies (such as public school districts), as defined in section 9101 of the Elementary and Secondary Education Act of 1965, as amended (ESEA).

Elementary school

An elementary school is a public or nonprofit private school, including a public elementary charter school, that provides elementary education, as determined under state law.

Full-time

You are considered to be a full-time teacher if you meet the standard used by the state where you teach in defining full-time employment as a teacher. If you are teaching in more than one school, the determination of full-time is based on the combination of all of your qualifying employment.

Highly-qualified teacher

The requirements to be considered a highly qualified teacher are different depending on whether you are a public school teacher or a private school teacher.

Requirements to be a highly-qualified public school teacher

If you are a teacher of public elementary or secondary school students (including a teacher employed by an educational service agency), to be considered highly-qualified you must—

• Have obtained full state certification as a teacher (including certification obtained through alternative routes to certification) or passed the state teacher licensing examination, and hold a license to teach in that state, except that if you are teaching in a public charter school, the term “highly qualified teacher” means that you meet the requirements set forth in the state’s public charter school law; and

• Not have had certification or licensure requirements waived on an emergency, temporary, or provisional basis.

In addition—

If you are a teacher of elementary school students who is new to the profession, you must hold at least a bachelor’s degree, and must have 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).

If you are a teacher of middle or secondary school students who is new to the profession, you must hold at least a bachelor’s degree, and must have demonstrated a high level of competency in each of the academic subjects in which you teach by—

• Passing a rigorous state academic subject test in each of the academic subjects in which you teach (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 you teach); or

• Successfully completing, in each of the academic subjects in which you teach, an academic major, a graduate degree, coursework equivalent to an undergraduate academic major, or advanced certification or credentialing.

If you are a teacher of elementary, middle, or secondary school students who is not new to the profession, you must hold at least a bachelor’s degree and must (1) meet the applicable standards of a teacher of elementary, middle, or secondary school students who is new to the profession; or (2) demonstrate competence in all the academic subjects in which you teach based on a highly objective, uniform state standard of evaluation that—

• Is set by the state for both grade appropriate academic subject matter knowledge and teaching skills;

• 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;

SECTION 6: DEFINITIONS (CONTINUED)

• Provides objective, coherent information about your attainment of core content knowledge in the academic subjects in which you teach;

• Is applied uniformly to all teachers in the same academic subject and the same grade level throughout the state;

• Takes into consideration, but is not based primarily on, the time you have been teaching in the academic subject;

• Is made available to the public upon request; and

• May involve multiple, objective measures of teacher competency.

Requirements to be a highly-qualified private school teacher

If you are a teacher in a private, non-profit elementary or secondary school and you are exempt from state teacher certification requirements, to be considered highly-qualified you must satisfy rigorous subject knowledge and skills tests by taking competency tests in the applicable grade levels and subject areas. The competency tests must be recognized by five or more states for the purposes of fulfilling the highly qualified teacher requirements for public school teachers as described above, and you must achieve a score on each test that equals or exceeds the average passing score for those states.

High-need fields

High-need fields are—

• Bilingual education and English language acquisition;

• Foreign language;

• Mathematics;

• Reading specialist;

• Science (including, but not limited to, computer science);

• Special education; or

• Any other high-need field listed in the Teacher Shortage Area Nationwide Listing (Nationwide List) at https://www2.ed.gov/about/offices/list/ope/pol/tsa.html that we issue annually and periodically update, including a geographic region of a state or a specific grade level designated as having a shortage of teachers.

To satisfy your TEACH Grant service obligation by teaching in a high-need field that is listed in the Nationwide List, the field must be listed for the state where you are teaching at the time you begin teaching in that field (even if the field later loses its high-need designation), or it must have been listed for the state where you are teaching at time you signed your Agreement or received a TEACH Grant (even if the field loses its high-need designation before you begin teaching in that field).

Low-income school

A low-income school is an elementary school, secondary school, or educational service agency (ESA) that is listed in the U.S. Department of Education’s Teacher Cancellation Low-Income Directory (TCLI Directory) at https://studentloans.gov/myDirectLoan/tcli.action. All elementary and secondary schools or educational service agencies operated by the U.S. Department of the Interior’s Bureau of Indian Education (BIE) or operated on Indian reservations by Indian tribal groups under contract or grant with the BIE qualify as low-income schools, even if they are not listed in the TCLI Directory.

If a school or ESA where you teach meets the requirements for inclusion in the TCLI Directory for all or a part of a school year of your required 4 school years of teaching, but does not meet those requirements in subsequent school years, those subsequent years of teaching at that same school or ESA will still qualify for purposes of satisfying your TEACH Grant service obligation.

School year

A school year is—

• One complete school year at the same school or for the same ESA; or

• Two complete and consecutive half school years at different schools or for different ESAs; or

• Two complete and consecutive half school years from different school years at either the same school or for the same ESA or at different schools or for different ESAs.

Half years do not include summer sessions. Two half school years generally fall within a 12-month period. For schools or ESAs that have a year-round program of instruction, a minimum of nine months is considered to be a school year.

Under limited conditions, less than a full school year of teaching may still be counted as one of your required 4 years. If you completed at least one-half of a school year of qualifying teaching, but were unable to teach for the remainder of the school year, that partial year may still be counted toward one of your required 4 years of teaching if—

• Your employer considers you to have fulfilled your contract requirements for the school year for the purposes of salary increases, tenure, and retirement; and

• You were unable to complete the full school year due to (1) a condition that is a qualifying reason for leave under the Family and Medical Leave Act of 1993 (FMLA), (2) a call or order to Federal or State active duty, or Active Service as a member of a Reserve Component of the Armed Forces named in 10 U.S.C. 10101, or service as a member of the National Guard on full-time National Guard duty, as defined in 10 U.S.C. 101(d)(5); or (3) residing in or being employed in a federally declared major disaster area as defined in the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. 5122(2).

Secondary school

A secondary school is a public or nonprofit private school, including a public secondary charter school, that provides secondary education, as determined under state law. However, a secondary school does not include any education beyond grade 12.

Teacher

A teacher is a person who provides direct classroom teaching or classroom-type teaching in a non-classroom setting, including special education teachers and reading specialists.

TEACH Grant servicer

Your TEACH Grant servicer (identified in the General Information and Instructions on page 1 and at the bottom of all other pages of this form) monitors your progress toward completing your TEACH Grant service obligation on behalf of the U.S. Department of Education.

SECTION 7: IMPORTANT NOTICES

PRIVACY ACT 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 §420L et seq. and §451 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1070g et seq. and 20 U.S.C. 1087a et seq.) and the authorities for collecting and using your social security number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and §31001(i)(1) of the Debt Collection Improvement Act of 1996 (31 U.S.C. 7701(c)). Participating in the Teacher Education Assistance for College and Higher Education (TEACH) Grant Program and/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 TEACH Grant, and, if a TEACH Grant that you receive is converted to a Direct Unsubsidized Loan, to determine your eligibility to receive a benefit on the loan (such as deferment, forbearance, discharge, or forgiveness), to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become 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, on a case-by-case basis or under a computer matching program, to third parties as authorized under routine uses in the appropriate systems of records notices.

The routine uses of the information that we collect about you, if your TEACH Grant has not been converted to a Direct Unsubsidized Loan, include, but are not limited to, its disclosure to federal, state, or local agencies, to institutions of higher education, and to third party servicers to determine your eligibility to receive a TEACH Grant, to investigate possible fraud, and to verify compliance with federal student financial aid program regulations.

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 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, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to creditors, to financial and educational institutions, and to guaranty agencies to verify your identity, to determine your program eligibility and benefits, to permit making, servicing, assigning, collecting, adjusting or discharging your loan(s), 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, or to verify whether your debt qualifies for discharge or cancellation. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state or local agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies.

To provide a standardized method for educational institutions to efficiently submit student enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies.

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 1845-0158. Public reporting burden for this collection of information is estimated to average 20 minutes (0.33 hours) per response, including time for reviewing instructions, searching existing data resources, 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 a benefit in accordance with 34 CFR 686.40(a).

If you have comments or concerns regarding the status of your individual submission of this form, write to:

U.S. Department of Education
FedLoan Servicing
P.O. Box 69184
Harrisburg, PA 17106-9184

Grant Recipient’s Name _______________________________________________________________ SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___

ADDITIONAL CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION
(TO BE USED IF A CERTIFICATION FROM MORE THAN ONE CHIEF ADMINISTRATIVE OFFICER IS REQUIRED)

SECTION 4: CHIEF ADMINISTRATIVE OFFICER’S (CAO’S) CERTIFICATION

Read the definitions in Section 6 before completing this section. Be sure to sign and date the form at the bottom of this page. Return the form to the grant recipient.

1. What is the name of the school or educational service agency (ESA) where the grant recipient taught? Enter the name and other information requested below, then continue to Question 2.

Note: If the grant recipient met the requirements for a full school year of teaching by teaching at different schools or for different ESAs and you are authorized to certify the recipient’s teaching service at each school or ESA (for example, if the recipient taught at different schools within the same school district), provide all information requested below for each school or ESA. Attach additional pages if necessary; include all information requested in this section.

School (not school district) or ESA Name __________________________________________________________________________________

Check here if this is a school or ESA 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 or ESA Address (Street, City, State, Zip Code) ____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

School or ESA Website _________________________________________________________________________________________________

School District ___________________________________________________________________________ County ______________________

2. Was the grant recipient a full-time, highly-qualified teacher during the school year(s) of teaching that you are being asked to certify?

Yes – Continue to Question 3.

No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.

3. Were more than half of the classes that the grant recipient taught in the high-need field(s) indicated by the grant recipient in Section 2?

Yes – Continue to Question 4.

No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.

4. Has the grant recipient met his or her contractual requirements (for purposes of salary increases, tenure, and retirement) for a full school year of teaching, and has that school year ended?

Yes – Continue to Question 5.

No – Do not complete this form. You can only certify teaching for a full school year of teaching that has ended.

5. Check the box below that describes how the grant recipient completed a full school year of teaching, then follow the instructions for the box that you check. Check only one box.

The grant recipient completed a full school year of teaching during one school year at the same school or for the same ESA. Continue to Question 6 and identify the school year.

The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years within the same school year at different schools or for different ESAs. Continue to Question 6 and identify the school year.

The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years of teaching during different school years at either the same school or for the same ESA or at different schools or for different ESAs. Skip to Question 7 and identify the school year.

6. The grant recipient taught for the full 20___ ___ – 20___ ___ school year.

7. The grant recipient taught for the second half of the 20___ ___ – 20___ ___ school year and for first half of the 20___ ___ – 20___ ___ school year.

I certify that the information I have provided above about the TEACH Grant recipient’s teaching service is true and correct.

CAO’s Name _____________________________________________________________________________________________________________

CAO’S Title (printed) ______________________________________________________________________________________________________

Telephone ( _______ ) _______ - _____________ Email _________________________________________________________________________

CAO’s Signature ____________________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

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