**OMB No. 1840-0753**

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

Teacher Quality Enhancement Program

Title II, Higher Education Act

Verification of Teaching Obligation

The individual identified on page two is a new teacher employed by your
school district. He or she received

a scholarship provided under the Teacher Quality Enhancement Program to
attend a teacher preparation program. As a condition of that
scholarship, within six months of completing the program, the individual
must begin teaching in a high-need school, as that term is defined in
Section II, Part C of this form. The individual must continue teaching
in a high-need school for a period equivalent to the length of time for
which he or she received the scholarship. The U. S. Department of
Education needs the information identified in this document so that it
can confirm that the individual has fulfilled this service obligation.

For Parts I and II, we ask that you furnish this information by October
1 for individuals who begin teaching at

the beginning of the school year, and within seven days of receipt for
individuals who begin teaching at other times. The Department needs to
obtain the information only once during the school year.

For Section III, we ask that you furnish the information on the
teacher's regular school-year employment in

your school district (Parts A1 and A2 and Part B) within seven days of
the end of the school year. If the individual teaches during the summer
(or intersession period if the school district operates a year-round
program) in a high-need school, we ask that you furnish the information
in Part A3 within seven days of the

end of the summer session. Please also include any changes in the name,
address, telephone number, fax number, or e-mail address of the school
district's reporting official that was previously provided in Section I.

Please mail this completed form to:

> U.S. Department of Education
>
> Office of Postsecondary Education
>
> Teacher Quality Enhancement Program
>
> 1990 K Street N.W., 7th floor
>
> Washington, DC 20006-8526

If you prefer to receive this information electronically, please contact
the Teacher Quality Enhancement Program Office by e-mail at
<teacherquality@ed.gov> or by telephone at: (202) 502-7878. You will be
sent an electronic copy of this document.

Thank you for your assistance.

**I. Scholarship Recipient / Teacher Information**

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Permanent Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

City, State, Zip Code:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## Permanent Telephone Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Social Security Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## Date of Birth: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Institution that Provided your Scholarship Assistance:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# II. School District / School Information

**Part A.**

School District:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Address:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of District Official Providing this Information:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title of District Official Providing this Information:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Telephone Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Fax Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ E-Mail:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ has
been employed by the school district as a teacher

(Name of Teacher)

at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(School Name)

 since the beginning of this school year /  beginning \_\_\_\_ weeks
after the school year began.

Part B.

During the current academic year, he/she will be teaching at this school

 full-time.  part-time.

If part-time, he/she has a teaching schedule that is \_\_\_\_\_% of the
district's full-time teachers.

Date on which the school year/term will end.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Part C.**

To retain his/her financial assistance as a scholarship,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(School Name)

must be a "high-need school " as the term is used in the Teacher Quality
Enhancement Grant Programs.

Please check at least one box that applies to the school:

1a.  40% or more of the enrolled students are eligible for free and
reduced lunch subsides; or

b\.  The school is otherwise eligible, without need of a waiver, to
operate as a schoolwide program under Title I of the Elementary and
Secondary Education Act.

2\.  34% or more of the school's academic classroom teachers do not
have a major, minor, or significant course work in their main assignment
field.

3\.  34% or more of the main assignment faculty in two of the
core-subject departments do not have a major, minor or significant work
in their main assigned field.

4\.  The school has had an attrition rate among classroom teachers of
15% or more over the last three school years.

NOTE: If none of these categories applies to the school in which the
individual is teaching, please notify the individual immediately. He or
she is at risk of becoming legally responsible for repayment of the full
amount of his/her scholarship.

##### Questions / Comments: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

I certify that the information contained in this document is correct. \*

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

## **Signature of School District Official Date**

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

## **Name of School District Official Title** 

**\* Note: Please provide original signature. Do [not]{.underline} use
rubber stamp.**

#### **Confirmation of School-Year /Summer Employment** 

(To be completed within seven days of the end of the school year or
summer / intersession period. Please submit this to the U.S. Department
of Education along with the previously completed SECTIONS I and II.)

Part A.

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

> (Name of Teacher)

1\.  Continued to teach at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> (School Name)

for the remainder of the school year in the same full-time or part-time
capacity as reported earlier this year.

2\.  Became a teacher at another school,
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,

> (School Name)

beginning \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ and taught there in the
same full-time or part-time capacity as

(Date)

previously reported. This is a high-need school because it meets the
criterion in Box \_\_\_\_ in Section II.C of this document.

3\.  Taught this summer / intersession period at:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

(School Name)

This is a high-need school because it meets the criterion in Box
\_\_\_\_ in Part II.C of this document. The individual taught at this
school from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ to
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.

(Date) (Date)

Part B.

If neither 1 nor 2 of Part A is true. Please explain the change of the
individual's employment status from what the school district reported in
Section II. If applicable, please also provide the date on which the
individual no longer was employed by the school district or worked in a
high-need school.

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

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

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

##### 

##### Questions / Comments: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

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

I certify that information contained in this document concerning
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ is correct.

(Name of Teacher)

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

## **Signature of School District Official \* Date**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

## **Name of School District Official Title**

**\* Original signature required. Do not use stamp.**

**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 .25
hours (or 15 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.