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Records Code: XTSP

## TEACH Grant Suspension/Military Discharge Request Form

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

**SECTION 1: TEACH GRANT RECIPIENT IDENTIFICATION**Please enter or correct the following information:

SSN	Name

Address	City	State	Zip

Address	Email (Optional)

Telephone-Primary	Telephone-Alternate

## SECTION 2: SUSPENSION/MILITARY DISCHARGE REQUEST

### Before completeing this form, carefully read the entire form, including the instructions, and other information in Sections 4,5,6 and 7. For the Military Service Suspension/Discharge request, a representative may complete and sign this form on your behalf if you are unable to do so.

**Request for Suspension of Service Obligation**

**I request**a temporary suspension of the 8-year period for completing my service obligation for the reason checked below. I request the suspension for a 12-

month period to cover the **full**academic year beginning

and ending

that I am or was

unable to teach to fulfill my service obligation. I have provided any required documentation (as described in Section 7).

### Check one:

I am/was enrolled in a program of study for which I would be eligible to receive a TEACH Grant (TEACH Grant-eligible program) or in a program     of study that has been determined by a state to satisfy the requirements for certification or licensure to teach in the state's elementary or
A

secondary schools. (If you check this box you must complete Section 3 and have an authorized official complete Section 4 to confirm your enrollment.)

B	    I have a condition that is a qualifying reason for leave under the Family and Medical Leave Act of 1993 (FMLA). (Check the box below to identify your qualifying FMLA condition and provide the requested information. See Section 6 for more information about the FMLA. If you check this box,

you must also complete Section 3.)

    For the birth of my child and to care for my newborn child. My child was born on	.

    For the placement of a child for adoption or foster care.  This child was placed with me on	.

    To care for my (check one)	    spouse	      child	      or parent

with a serious health condition. I began caring for this individual on	.

Because of a serious health condition that makes me unable to perform the functions of my job. This condition made me unable to work

beginning	.

    To care for a covered servicemember (as defined in 29 CFR 825.127) with a serious injury or illness. I began caring for this individual on

, and I am the	    spouse	     child        parent	or next of kin of the servicemember.

**Note:**A qualifying exigency (as defined in 29 CFR 825.126) arising out of 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 is an additional condition for FMLA leave. If you believe you qualify for a suspension due to a qualifying exigency, carefully review Section 7 and contact your grant servicer (see Section 8)**.**

Recipient Name	Recipient SSN

I am a member of a reserve component of the Armed Forces and have been called to active duty status for more than 30 days, or I am a

C	     member of the National Guard on full-time National Guard duty under a call to active service in connection with a war, military operation, or national emergency, as defined in Section 6. (If you check this box you must complete Section 3 and have your Commanding or Personnel

Officer complete Section 4, or provide a copy of your military orders as described in the instructions for Section 4.)

### Request for Military Discharge of Service Obligation

I have received the maximum 3 years of suspension for qualifying active duty military service, but I am subject to an extended call or order to active duty status as a member of the Armed Forces of the United States, as defined in Section 6. I request a proportional discharge of my service
****

D

obligation, as described in Section 7. (If you check this box you must complete Section 3 and have your Commanding or Personnel Officer complete Section 4, or provide a copy of your military orders as described in the instructions for Section 4.)

## SECTION 3: RECIPIENT UNDERSTANDINGS AND CERTIFICATION

### · I understand that:

(1) My TEACH Grant servicer will not grant this suspension or discharge unless I have completed all applicable sections of this form and provided any required documentation.

(2) I can receive one 12-month period of suspension of the period for completing my service obligation at a time. I may reapply for another suspension

at the end of the 12-month period if I continue to meet the eligibility requirements. The maximum period for which I may receive a suspension is three years combined for suspensions based on enrollment in a qualifying program of study or an FMLA condition, and three years for suspension based on qualifying military service.

(3) My suspension request must be received by TEACH Grant servicer before I am subject to any of the conditions that would cause my TEACH Grant to be converted to a Direct Unsubsidized Loan as explained in my Agreement to Serve.

(4) By signing this form, I am certifying my intent to fulfill my service obligation, regardless of whether or not my suspension or discharge request is approved.

(5) If I am granted a discharge of a portion of my TEACH Grant service obligation based on qualifying military service, I am responsible for completing the remaining period of my service obligation in accordance with the terms and conditions specified in my Agreement to Serve.

### · 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 or discharge that I have requested, as explained in Sections 2, 6, and 7; and

(3) I will provide my TEACH Grant servicer with additional documentation, as required, to support my suspension or discharge request.

Date:

**Signature of Recipient or Recipient's Representative**

Printed name of Recipient's Representative (if applicable)

Relationship to Recipient

Address of Recipient's Representative

Telephone

## SECTION 4: AUTHORIZED OFFICIAL'S CERTIFICATION

**This section must be completed *ONLY if item A, C or D is checked in Section 2.***

***Note: As an alternative to completing this section, for the military suspension/discharge only, separate documentation from the Commanding or Personnel Officer that includes all of the information requested below may be attached or, a copy of the TEACH Grant recipient's military orders and military identification may be submitted. The orders must include all information needed to establish the recipient's eligibility for the suspension or discharge as indicated in Sections 2 and 7, including the period of the qualifying active duty service.***

**I certify**that the TEACH Grant recipient identified in Section 1 is/was enrolled in an eligible program of study or is/was performing qualifying military service that qualifies the individual for the suspension or discharge indicated in Section 2 and meets the eligibility requirements described in Section 7.

The recipient's enrollment in a qualifying program of study OR qualifying military service begins/began on	and ends/ended on

# .

# 

Name of Institution, Military Branch or National Guard Component:

# Address

City

State	ZIP	Telephone

Name & Title of Authorized Official (please print):

Date

Authorized Official's Signature

## SECTION 5: INSTRUCTIONS

Type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only numbers. Example: January 31, 2013 = 01-31-2013. Include your name and account number on any documentation that you are required to submit with this form. If you need help completing this form, contact your TEACH Grant servicer.

Return the completed form and any required documentation to the address shown in Section 8.

## SECTION 6: DEFINITIONS

· For the **In-School suspension**only (Section 2, Item A):

· A **TEACH Grant eligible program**is a program of study that is designed to prepare an individual to teach as a highly-qualified teacher in a high- need field and leads to a baccalaureate or master's degree, or is a post-baccalaureate program of study. A two-year program of study that is acceptable for full credit toward a baccalaureate degree is considered to be a program of study that leads to a baccalaureate degree.

· A **high need field**includes: billingual education and English language acquisition; foreign language; mathematics; reading specialist; science; specila education; and any other field documented as high need by the Federal Government, a State government or an LEA, and approved by the Department and listed in the Department's annual Teacher Shortage Area Nationwide Listing.

· An **authorized official**who may complete section 4 is an official of the school where you are/were enrolled as a student in a TEACH Grant-eligible or in a program of study that has been determined by a state to satisfy the requirements for the certification of licensure to teach in the state's elementary or secondary schools.

· For the **FMLA suspension**only (Section 2, Item B):

· Conditions that are **qualifying reasons for leave under the Family and Medical Leave Act of 1993 (FMLA)**are defined in 29 CFR 825.112 and include: (1) Birth of a son or daughter, and caring for the newborn child; (2) Placement with you of a son or daughter for adoption or foster care; (3) Caring for your spouse, son, daughter, or parent with a serious health condition; (4) A serious health condition that makes you unable to perform the functions of your job; (5) Caring for a covered servicemember with a serious injury or illness if you are the spouse, son, daughter, parent, or next of kin of the servicemember; and (6) Qualifying exigency arising out of the fact that your spouse, son, daughter, 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 these qualifying reasons for leave under the FMLA, go to http://www.dol.gov/whd/fmla/.

· For the **Military Service suspension**only (Section 2, Item C):

· **Full-time National Guard duty**means training or other duty, other than inactive duty, performed by a member of the National Guard of the United States or the Air National Guard of the United States in the member's status as a member of the National Guard of a State or territory, the Commonwealth of Puerto Rico, or the District of Columbia under section 316, 502, 503, 504, or 505 of title 32 for which the member is entitled to pay from the United States or for which the member has waived pay from the United States.

· The **reserve components of the Armed Forces**are the following: the Army national Guard of the United States, the Army reserve, the Navy Reserve, the **Marine Corps reserve, the Air National Guard of the United States, the Air Force Reserve, and the Coast Guard reserve.**

· An **authorized official**who may complete Section 4 is your Commanding or Personnel Officer.

· For the **Military Service discharge**only (Section 2, Item D):

· The **Armed Forces of the United States means**the Army, Navy, Air Force, Marine Corps, and the Coast Guard.

· An **authorized official**who may complete Section 4 is your Commanding or Personnel Officer.

## SECTION 7: ELIGIBILITY REQUIREMENTS FOR SUSPENSION OR MILITARY SERVICE DISCHARGE

### · In-school Suspension (Section 2, Item A)

· You must have an authorized official complete Section 4 of this form.

· You must be enrolled in a TEACH grant eligible program of study or in a program of study that has been determined by a state to satisfy the requirements for certification or licensure to teach in the state's elementary or secondary schools.

· The maximum amount of time you are eligible for this suspension is 3 years. (This is a combined limit with the FMLA suspension)

· 

### · FMLA Suspension requirements (Section 2, Item B)

· You must have a condition that would be a qualifying reason for leave under the FMLA, as defined in Section 6. **Note:**A “qualifying exigency” related to a covered service member's active duty status would generally support only a relatively brief period of FMLA leave. To qualify for a suspension of the period for completing your TEACH Grant service obligation based on this qualifying reason for leave under the FMLA, your exigency must prevent you from completing an academic year of teaching service. Contact your TEACH Grant servicer if you believe you qualify for a suspension based on a qualifying exigency.

· You must complete Section 2 by checking the appropriate box to identify the reason for which you would qualify for leave under FMLA and must provide the requested information for the reason that you check.

### · The maximum amount of time you are eligible for this suspension is 3 years (This is a combined limit with the In-School suspension).

· **Military Service Suspension**

· You must be subject to a call/order to active duty status for more than 30 days as a member of a reserve component of the Armed Forces named in 10 U.S.C. 10101(see Section 6), 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) (see Section 6) under a call to active service in connection with a war, military operation, or a national emergency.

· You must have your Commanding or Personnel Officer complete Section 4 of this form; or you may provide your TEACH Grant servicer with **(1)**a copy of your military orders and copy of your military identification, or **(2)**a written statement from your Commanding or Personnel Officer certifying **(a)**that you are a member of a reserve component of the Armed Forces called or ordered to active duty; **(b)**the date on which your service began; and if available, **(c)**the date on which your service is expected to end.

· The maximum amount of time you are eligible for this suspension is 3 years. If you have exhausted your eligibility for suspension due to military service but are subject to an extended call or order to active duty status as a member of the Armed Forces of the United Stated, as defined in Section 6, you may request a proportional discharge of your service obligation.

### · Military Service Discharge

· You must have received the maximum 3 years of suspension for qualifying active duty military service, and must be subject to an extended call or order to active duty status as a member of the Armed Forces of the United States, as defined in Section 6. You may qualify for a proportional discharge of your TEACH Grant service obligation as follows: **(1)**one-year discharge if a call or order to active duty status is for more than three years, **(2)**two- year discharge if a call or order to active duty status is for more than four years, **(3)**three-year discharge if a call or order to active duty status is for more than five years, **(4)**full discharge if a call or order to active duty status is for more than six years.

· You must have your Commanding or Personnel Officer complete Section 4 of this form; or you may provide your TEACH Grant servicer with **(1)**a copy of your military orders and a copy of your military identification, or **(2)**a written statement from your Commanding or Personnel Officer certifying **(a)**that you are on active duty with the Armed Forces of the United States as defined in Section 6; **(b)**the date on which your service began; and **(c)**the date on which your service is expected to end.

· If you receive a discharge of a portion of your TEACH Grant service obligation, you remain responsible for completing any portion of the service obligation that is not discharged.

## SECTION 8: WHERE TO SEND THE COMPLETED SUSPENSION/DISCHARGE REQUEST FORM

### Return completed form and any attachments to:

**U.S. Department of Education**

**P.O. Box 69184 Harrisburg, PA 17106-9184 or Fax to: 717-720-1628**

**If you need help completing this form, call:**

**1-800-699-2908**

**International: 717-720-1985**

**TDD: 1-800-722-8189**

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