**OMB No. 1840-0753**

**Expiration Date: 4/30/2011**

**TEACHER QUALITY ENHANCEMENT PROGRAMS**

## **TITLE II, HIGHER EDUCATION ACT (HEA)**

###### **SCHOLARSHIP TERMS AND CONDITIONS**

## **SECTION I: RECIPIENT SECTION**

Name (last, first, middle initial):

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

Date of Birth:

Area Code/Phone Number:

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:

##### SECTION III: TERMS AND CONDITIONS 

**A. Applicable Law**

The terms of this agreement and any scholarship assistance received with
funds provided under Title II, sections 202- 204, of the Higher
Education Act of 1965, as amended (the "Act") that the recipient
receives will be interpreted in accordance with Title II, section 204,
of the Act and any applicable Federal regulations. Section 204 of the
Act embodies the Teacher Recruitment Program, whose purpose is to
address the severe shortages of qualified teachers in many school
districts and schools throughout the nation.

B.  **Purpose of the Scholarship -- the Recipient's Service Obligation**

Section 204(e) of the Act authorizes institutions and States that
receive Teacher Recruitment Program funds from the U.S. Department of
Education (the Department) to use these funds to provide scholarships to
qualified individuals who agree to become teachers and then work in
school districts and schools that face a serious teacher shortage.
Similarly, sections 202(d)(7) and 203(e)(4) of the Act authorize States
and institutions that receive State or Partnership Program grants
respectively to use these funds to carry out activities permitted under
the Teacher Recruitment Program. Therefore, recipients of scholarships
provided with federal funds under these two programs also are subject to
the requirements of section 204(e) of the Act.

Consistent with section 204(e), the recipient accepts the scholarship
with the understanding that it carries with it a service obligation.
More specifically, in exchange for the scholarship, the recipient agrees
upon graduating from the institution's teacher training program to teach
in a "high-need school" of a "high-need local educational agency
(hereinafter "high-need school district") for at least as long as the
period for which the recipient receives scholarship assistance. The
recipient understands that the period of time for which he or she
receives scholarship assistance will be determined in comparison to
full-time enrollment in the teacher preparation program (exclusive of
summers). Similarly, the recipient understands that the period of time
he or she must teach in a high-need school of a high-need school
district will be determined in comparison to what the school district
considers to be teaching on a full-time basis. Full-time basis does not
include summers or optional intersession periods for those school
districts that operate year-round programs.

The recipient also understands that the institution has received funds
from the Department of Education to provide teacher recruitment services
to the scholarship recipient and so, consistent with section 204 of the
Act, is responsible among other things for \--

1.  Providing support services, if needed, to help the recipient
    complete the teacher training program;

2.  Working with one or more high-need school districts, to secure
    placement of the scholarship recipient, upon his or her graduation,
    into a teaching position at a high-need school in the school
    district; and

3.  Working with the high-need school and school district in which the
    recipient begins to teach to provide the recipient with follow-up
    services during his or her first three years of teaching.

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C.  **Recipient's Retention of Scholarship Assistance for Meeting the
    Service Obligation**

The recipient does not have to repay to the Department the scholarship
provided with funds under Title II of the Act if the Department
determines that the recipient has fulfilled his or her service
obligation. To determine that the recipient has met the service
obligation, the Department must receive information to confirm that the
recipient (1) within six months of graduation from the teacher training
program, is teaching in a high-need school of a high-need school
district; and (2) continues teaching in a high-need school of a
high-need school district for a period of time that is equivalent to the
period of time for which the recipient receives this scholarship
assistance.

So that the Department may obtain the information it needs to make these
determinations, the recipient agrees within six (6) months of graduating
from the institution's teacher training program to have the high-need
school district in which he or she is teaching provide to the Department
information as the Department may require that confirms:

1.  The school and school district in which the recipient is teaching
    are "high-need" as defined in the "**Definition of High-Need School
    District and High-Need School**," below; and

2.  The recipient is teaching on a full-time basis or, if teaching on a
    part-time basis, the amount of time the recipient is teaching as a
    percentage of the time spent teaching by the district's full-time
    teachers.

Before graduating, the institution will provide the recipient written
guidance that explains the information the recipient must have the
school district provide the Department, and the date or dates that this
information is due.

\[NOTE: To prevent a scholarship recipient becoming liable for repaying
the scholarship and interest because of a school district's delay in
forwarding the required employment information to the Department, the
Department also will accept employment information directly from the
recipient. In this case, within six months of graduating from the
teacher preparation program, the scholarship recipient must submit to
the Department (1) a notarized statement that he or she has asked the
district to provide the needed information and the date this request was
made, and (2) a copy of the personal and employment information that the
district has been asked to submit. When a scholarship recipient chooses
the second option, the Department\'s determination that he or she is
meeting the service obligation is only provisional. Until the district
provides the information, the scholarship recipient retains a continuing
responsibility to work to get the district to submit it as soon as
possible.\]

Scholarship recipients who attend the institution on a part-time basis
must teach in a high-need school of a high-need school district for a
period that is comparable to the full-time equivalent period that the
student receives scholarship assistance. The Department treats both the
full academic year of the teacher training program, excluding summer,
and the full academic year of the school district in which the recipient
will teach, excluding summers and any intersession periods (for school
districts that operate year-round programs), as equivalent one-year
periods of time.

> EXAMPLE: An individual receives a scholarship for the costs of
> attending a teacher preparation program on a part-time basis. While
> the program extends for two full years of coursework and clinical
> experience, the scholarship recipient is enrolled part-time, and
> completes the program in three years. The Department would consider
> the period for which the individual receives a scholarship as two
> academic years.

Upon graduation, the individual begins teaching half time in a high-need

school of a high-need school district after receiving the two full years
of

scholarship support. If the individual continues to teach half time, he
or

she would meet the program's service obligation by teaching in a high-

need school of a high-need school district for the standard contractual

period of four school years. This four-year period is equivalent to the

period that a full-time teacher would teach for two full school years.

At the end of each school year, the recipient will have the high-need
school district in which he or she teaches provide the Department with
information to confirm that the recipient has taught for the preceding
period in a high-need school. \[The Department alternatively accepts the
same kind of notarized statement and accompanying information that is
described in the "NOTE" at the bottom of the preceding page and top of
this page regarding the initial employment information that the
Department needs.\] The Department will provide the recipient with
credit toward meeting the service obligation for time that a high-need
school district confirms the recipient has taught in a high-need school
of a high-need school district during a summer period (or intersession
period for districts that operate year-round programs).

Until the Department notifies the recipient that he or she has met the
service obligation, at the beginning and end of each subsequent academic
year the recipient will continue to have the high-need school district
inform the Department whether the recipient is teaching in a high-need
school. The recipient will have the school district provide this
information on or before October 1 and within seven days of the end of
the school year, respectively.

Before graduation, the institution will provide the recipient forms that
contain the information that the school districts will need to provide
to the Department.

D.  **Definition of High-Need School District and High-Need School**

For purposes of this agreement, a "high-need school district" is a
school district that meets one of the following definitions:

1.  A school district with at least one school --

> In which 40 percent or more of the enrolled students are eligible for
> free and reduced lunch subsidies, or
>
> That otherwise is eligible, without receipt of a waiver, to operate as
> a schoolwide program under Title I of the Elementary and Secondary
> Education Act.

2.  A school district that has at least one school where --

More than 34 percent of academic classroom teachers overall (across all

academic subjects) do not have a major, minor, or significant course
work in

their main assignment field; or

> More than 34 percent of the main assignment faculty in two of the
> core-
>
> subject departments do not have a major, minor, or significant course
> work in their main assignment field.

(For purposes of the definition above, "main assignment field" means

the academic field in which teachers have the largest percentage of

their classes.

"Significant course work" means four or more college- or graduate-

level courses in the content area.)

3.  A school district that serves a school whose attrition rate among
    classroom teachers was 15 percent or more in the last three school
    years.

For purposes of this Agreement, a "high-need school" is an elementary or
secondary school that meets one of the three tests that enables a school
district to be considered a "high-need school district."

E.  **Deferment of Service Obligation**

The Department may defer the scholarship recipient's responsibility to
teach in a high-need school of a high-need school district if the
recipient provides satisfactory information to confirm that he or she --

1.  Suffers from a serious physical or mental disability that
    temporarily prevents or impairs the scholarship recipient from
    working as a teacher;

2.  Is a member of the Armed Forces of the United States on active duty;

3.  Is conscientiously seeking but is unable to secure employment (for
    reasons that may include the failure to pass a required teacher
    certification or licensure examination) as a teacher in a high-need
    school of a high-need school district; or

4.  Is affected by other extraordinary circumstances that prevent the

> scholarship recipient from securing such employment.

The recipient must apply to the Department for a deferment of the
service obligation. The recipient must do so within six (6) months of
his or her graduation (or withdrawal) from the teacher training program
or, if the recipient has already begun teaching in a high-need school of
a high-need school district, within six (6) months of the date he or she
no longer teaches in this school. Unless the Department determines
otherwise, the recipient must apply to the Department to renew a
deferment on a yearly basis. Deferments for military service may not
exceed three years. During the period of any deferment, the recipient
agrees to provide the Department with current information (including
updating information) on the recipient's home address and phone number,
and work address and phone number.

The obligation to repay the scholarship, as set forth below in
"**Repayment for Failure to Meet Service Obligation,"** is not deferred
until the Department determines that a deferment is appropriate.

F.  **Repayment for Failure to Meet Service Obligation**

The recipient agrees to repay to the Department the full amount of the
scholarship (with accrued interest and costs of collection, if any, as
described below) if he or she does not --

1.  Meet the service obligation or reporting requirements identified
    above

> in "**Recipient's Retention of Scholarship Assistance for Meeting**
>
> **the Service Obligation;"** or

2.  Receive a deferment of this obligation as explained above in

> "**Deferment of Service Obligation**."

If the scholarship recipient does not teach in a high-need school of a
high-need school district within six (6) months of his or her graduation
from the teacher preparation program, the recipient becomes obligated to
repay the scholarship six (6) months after the date of completion of the
teacher training program.

If the scholarship recipient withdraws from the teacher preparation
program prior to graduating, the recipient becomes obligated to repay
the scholarship six (6) months after his or her withdrawal from the
program.

If upon graduation from the institution's teacher preparation program
the scholarship recipient teaches in a high-need school of a high-need
school district for a period that is **less than** the period of his or
her service obligation, the recipient becomes responsible for repayment
of the percentage of the scholarship (and interest that accrues on this
portion of the scholarship) equal to the percentage of the period for
which the service obligation was not fulfilled.

> EXAMPLE: An individual receives a scholarship in the total amount of
> \$10,000 to attend a teacher preparation program for two academic
> years. The individual graduates from the program, and works in a
> high-need school of a high-need school district for one full school
> year. The individual then moves, and takes a teaching position in a
> school and school district that are not high-need.
>
> The individual has fulfilled one-half of his or her service
> obligation, and so must repay one-half of the scholarship, plus
> interest that accrues on this amount beginning six months after
> graduation from the teacher preparation program (see **"Interest**,"
> below), and any costs of collection. This indebtedness attaches to the
> recipient six months after the individual is no longer employed as a
> teacher in the high-need school of a high-need school district.

Until the scholarship recipient either satisfies the service obligation
or repays the scholarship, interest, and costs of collection, if any,
the recipient agrees to provide the Department a current home address
and telephone number, and a current work address and telephone number,
as well as other needed identifying information. In addition, the
recipient understands that the Department, the institution, and the
high-need LEA are or will be using the recipient's social security
number so that the Department can, if necessary, secure payment of these
amounts from the recipient if he or she fails to meet the service
obligation.

G.  **Availability of Monthly Payment Schedule**

Upon request, the Department will provide to the recipient a monthly
payment schedule. Unless, for cause, the Department establishes another
repayment schedule, the schedule will require the recipient to repay the
Department the full amount of the scholarship and accrued interest in
minimum monthly payments of no less than \$50 per month. However, the
payment schedule must enable the recipient to repay all scholarship and
accrued interest that is due within ten years of the date the recipient
becomes responsible for repaying these amounts.

The first payment will be due 30 days after the Department notifies the
recipient of the payment schedule, or at such subsequent time that the
Department may identify.

H.  **Interest**

In accordance with 31 U.S.C. 3717 and 34 CFR Part 30, the recipient
agrees to pay interest on the unpaid balance that the scholarship
recipient owes for failure to meet the service obligation. Interest will
begin to accrue as of the date the recipient becomes responsible for
repayment of the scholarship. See **"Repayment for Failure to Meet
Service Obligation**," above. No interest is charged for the period of
time that precedes the date on which the scholarship recipient becomes
responsible for repayment. Interest accrues during any period in which
the Department defers the service obligation, but is waived if the
scholarship recipient completes the service obligation.

The Department will notify the recipient of the prevailing interest rate
at the time a repayment schedule is established.

I.  **Collection of Defaulted Repayment Obligation**

The Department may take any action authorized by law to collect the
amount of scholarship, accrued interest and collection costs, if any, on
which a scholarship recipient obligated to repay under this section has
defaulted. Actions available to the Department include, but are not
limited to, filing a lawsuit against the recipient, reporting the
default to national credit bureaus, and requesting the Internal Revenue
Service to offset the recipient's Federal income tax refund.

J.  **Discharge of a Required Repayment**

The Department discharges an obligation to repay the scholarship and
interest of a scholarship recipient who has died or who demonstrates to
the Department's satisfaction that, because of permanent physical or
mental disability, he or she is not employable as a teacher.

Upon receipt of acceptable documentation and approval of the discharge
request, the Department returns to the scholarship recipient, or for a
discharge based on death, the recipient's estate, those payments
received after the date the eligibility requirements for discharge were
met and prior to the date the discharge was approved. The Department
also returns any payments received after the date the discharge was
approved.

K.  **Exit Conference**

Before the recipient graduates, withdraws from the institution, or
withdraws from the teacher preparation program, the institution will
provide the recipient an opportunity to review fully the terms and
conditions of this scholarship.

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

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### 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.

####### Paperwork 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. The valid OMB control
number for this information collection is 1840-0753. The time required
to complete this information collection is estimated to average
approximately 20 minutes per response, including the time to review
instructions, search existing data resources, gather 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, D.C. 20202-4651. If you have comments or concerns regarding
the status of your individual submission of this form, write directly
to: U.S. Department of Education, Office of Postsecondary Education,
Teacher Quality Enhancement Program, Coordinator of Teacher Recruitment,
1990 K Street N.W., 6th floor, Washington, DC 20006-8525.