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Records Code: XTAC

**TEACH GRANT CERTIFICATION**

**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: TEACH GRANT RECIPIENT'S UNDERSTANDINGS AND CERTIFICATIONS

### Before completing this section, carefully read the entire form, including the instructions, definitions, terms and conditions, and important notices in Sections 4, 5, and 6.

· **I understand**that:

· I must fulfill a teaching service obligation (service obligation) for each academic program for which I received a TEACH Grant, as stated in the Agreement to Serve (Agreement) that I signed before receiving each TEACH Grant. If I do not fulfill my service obligation, all TEACH Grant funds that I received will be converted to Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans) that I must repay to the U.S. Department of Education (the Department), with interest charged from the date of each TEACH Grant disbursement.

· To fulfill my service obligation, I must teach full time for a total of at least four academic years within eight years after I complete or otherwise cease to be enrolled in the program for which I received TEACH Grant funds. My teaching service must meet the requirements specified in Section 6 and in my Agreement.

· After completing each of the four academic years of required teaching service, I must provide my TEACH Grant servicer with documentation of my teaching service by providing the information requested in Item A below and obtaining a certification in Section 3 of this form from the Chief Administrative Officer for the school or educational service agency where I taught.

· If I am not teaching, I must certify my intent to satisfy my teaching service obligation by checking the box in Item B below and signing the form. (If you did not complete your TEACH Grant program of study, see Section 6.)

· **I certify**that:

(A) I taught full time for one complete academic year, as certified in Section 3 (if you check this box for this reason you must complete items 1,2 and 3 below, and sign the form. Your Chief Administrative Officer must complete Section 3.) **Or**

I am currently performing qualifying teaching service, but have not yet taught for a complete academic year (If you check this box for this reason you must complete 1,2 and 3 below, and sign the form. If you did not complete the program for which you received your TEACH grants, your Chief Administrative Officer must complete Section 3 and indicate that you have not taught a complete academic year using the check box provided.)

(1) I am teaching or have taught full time as a highly-qualified teacher at a/an (check only**one******box):

   Low-income elementary or secondary school        Low-income educational service agency       Elementary or secondary school operated by the Bureau of Indian Education (BIE) or operated on an Indian reservation by an Indian tribal group under contract with the BIE.

(2) During the year of teaching listed below and as certified in Section 3, more than half of the classes I am teaching or have taught were in one or more of the following high-need fields **(check all that apply):**

    Mathematics       Science        Foreign Language       Bilingual Education       English Language Acquisition      Special Education	     Reading Specialist

     Other high-need field (see Section 5; list the other high-need field and grade level taught):

(3) I am teaching or have taught at:

Name of School (Not School District) or Educational Service Agency at which I am teaching

School Website

Address of School or Educational Service Agency

City	State	Zip Code

(B)

(C)

    I am not teaching, but I intend to satisfy my TEACH Grant service obligation. (If you check this box you only need to sign below)

I did not complete my TEACH Grant-eligible program of study and am not teaching, but I have re enrolled in another eligible program of study, as defined in Section 5. (If you check this box, sign the form and have an authorized official complete Section 3 to confirm your enrollment in an eligible program. In addition, you may contact us to request a suspension of the eight-year period for completing your service of obligation).

(D)	    The information I provided in Sections 1 and 2 is true and correct.

(E)	      I have read and understand the definitions in Section 5 and the terms and conditions in Section 6.

(F)	     My teaching service met the requirements specified in Section 6.

Recipient Name	Recipient SSN

Today's Date

TEACH Grant Recipient's Signature

## SECTION 3: CHIEF ADMINISTRATIVE OFFICER or AUTHORIZED OFFICIAL'S CERTIFICATION

### Before completing this section, carefully read the instructions, definitions, and terms and conditions in Section 4, 5, and 6. If recipient is teaching, complete as Chief Administrative Officer. Return the completed form to the grant recipient identified in Section 1. If the recipient is enrolled in a TEACH Grant eligible program of study, complete as Authorized Official.

**Chief Administrative Officer only: I certify**that the grant recipient identified in Section 1 *taught*during the academic year as a full-time highly-qualified teacher (as defined in Section 5) from

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at the eligible low-income elementary school, secondary school or educational service agency identified by the grant recipient in section 2, and that during this year the grant recipient taught more than half of his or her classes in the high-need field(s) identified by the grant recipient in section 2.

Check here if certifying teaching service for less than a complete academic year.

**Authorized Official only: I certify**that the grant recipient identified in Section 1 *is/was enrolled*at

(Name of Institution) in an eligible program, as defined in Section 5 during the academic period from date	to date	.

Telephone

### Chief Administrative Officer/Authorized Official's Name and Title (Printed)

Today's Date

### Chief Administrative Officer/Authorized Official's Signature

**SECTION 4: GENERAL INFORMATION AND 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.

· If you are certifying teaching service, the Chief Administrative Officer for the school or educational service agency where you performed your qualifying teaching service must complete Section 3. If you taught at more than one school or educational service agency during the same academic year, you may complete one certification form for each school or educational service agency at which you taught if one school or educational service agency cannot certify your complete academic year of teaching.

· If you are certifying enrollment in an eligible program of study, an Authorized Official for the school at which you are/were enrolled in the eligible program of study must complete Section 3.

### · Return the completed form and any attached pages to the address shown in Section 7.

### · 

**SECTION 5: DEFINITIONS**

· An academic year or its equivalent is one complete elementary or secondary school year, or two complete and consecutive half-years from different school

years (excluding summer sessions) that generally fall within a 12-month period. If a school or educational service agency has a year-round program of instruction, a minimum of nine months is considered to be the equivalent of an academic year.

· An authorized official who may complete Section 3 is an official of the school at which you are/were enrolled in a TEACH Grant-eligible program.

· The Chief Administrative Officer for a school or educational service agency is the individual who has access to the employment records which establish that the grant recipient’s teaching service met the requirements of the TEACH Grant Program, as explained in Section 6, and who is authorized to verify the grant recipient’s qualifying teaching service. The Chief Administrative Officer may vary depending on the teacher’s employer, and could include (but is not limited to) the principal or assistant principal of the school where the grant recipient taught, the superintendent, assistant superintendent, or human resources director for a school district or educational service agency, or the chief executive officer of an educational services agency.

· An **eligible program of study**is one that is TEACH Grant-eligible and 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. An eligible program of study is also 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.

· A **high-need**field includes the following: (1) bilingual education and English language acquisition; (2) foreign language; (3) mathematics; (4) reading specialist;

(5) science; (6) special education; and (7) any other field listed in the U.S. Department of education's (the Department's) annual Teacher Shortage Area Nationwide Listing (Nationwide List).

· Bilingual education is an educational program in which two languages are used to provide content matter instruction. English language acquisition is the process of acquiring English as a second language.

· **Special education**means specially designed instruction, at no cost to parents, to meet the unique needs of a child with a disability, including instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings; and instruction in physical education, i.e., physical therapy. A **child with a disability**is a child who needs special education and related services because the child has mental retardation, a hearing impairment (including deafness), a speech or language impairment, a visual impairment (including blindness), a serious emotional disturbance, an orthopedic impairment, autism, a traumatic brain injury, another health impairment, or a specific learning disability. For a child age 3 through 9, the term a child with a disability may, at the discretion of the state and the local educational agency, include a child who needs special education and related services because the child is experiencing developmental delays, as defined by the state and as measured by appropriate diagnostic instruments and procedures, in one or more of the following areas: physical development, cognitive development, communication development, social or emotional development, or adaptive development.

· A **post-baccalaureate program of study**is a program of instruction for individuals who have completed a baccalaureate degree that, (1) does not lead to a graduate degree ; (2) consists of courses required by a State in order for a student to receive a professional certification or licensing credential that is required for employment as a teacher in an elementary school or secondary school in that State, except that it does not include any program of instruction offered by a TEACH Grant-eligible institution that offers a baccalaureate degree in education; and (3) is treated as an undergraduate program of study for the purposes of title IV of the Higher Education Act.

### · A school or educational service agency serving low-income students (low-income school or low-income educational service agency) is an elementary

or secondary school or educational service agency that: (1) is in the school district of a local educational agency that is eligible for assistance under title I of the Elementary and Secondary Education Act; (2) has been determined by the Department to be a school in which more than 30 percent of the school’s total enrollment is made up of children who qualify for services provided under title I of the Elementary and Secondary Education Act; and (3) is listed in the Department’s Annual Directory of Designated Low-Income Schools for Teacher Cancellation Benefits. All elementary and secondary schools 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. If the school or educational service agency where you teach meets the low-income requirements during all or a part of a school year of my required four school years of teaching, but does not meet those requirements in subsequent school years, those subsequent years of teaching at that school or educational service agency will still qualify for purposes of satisfying my TEACH Grant service obligation.

· An **educational service agency**is a regional public multiservice agency authorized by State statute to develop, manage and provide services or programs to local educational agencies, as defined in section 9101 of the Elementary and Secondary Education Act of 1965 as amended.

· An **elementary school**is a nonprofit institutional day or residential school, including a public elementary charter school, that provides elementary education as defined under State law.

· A **secondary school**is a nonprofit institutional day or residential school, including a public secondary charter school, that provides secondary education, as determined under State law, except that the term does not include any education beyond grade 12.

· The **Teacher Education Assistance for College and Higher Education (TEACH) Grant Program**provides funds to students who are completing or who plan to complete coursework that is required to begin a career in teaching.

· 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. School librarians, guidance counselors, and other administrative staff are not considered teachers for the purposes of fulfilling the TEACH Grant service obligation.

· A **full time teacher**is a teacher who meets the standard used by a State in defining full-time employment as a teacher. For an individual teaching at

more than one school or educational service agency, the determination of full-time is based on the combination of all qualifying employment.

· The **highly-qualified teacher**requirements are specified in section 9101(23) of the Elementary and Secondary Education Act of 1965, as amended,or, for special education teachers, in section 602910) of the individuals with Disabilities Act.

**SECTION 6: TEACH GRANT PROGRAM TERMS AND CONDITIONS**

· For each academic program for which you receive TEACH Grant funds, you must complete a service obligation by teaching full time for a total of at least four academic years:

· As a **highly-qualified teacher**(see Section 5);

· At a **school or educational service agency serving low-income students**(see Section 5); and

· In a **high-need field**(see Section 5) in more than half of the classes that you teach during each academic year.

· You must complete the required four years of teaching within eight years after you complete or otherwise cease to be enrolled in the program for which you received the TEACH Grant.

· 

· After completing each year of your required four years of teaching service, you must complete and submit this TEACH Grant Certification to the Department.

· If you received a TEACH Grant but do not complete the required four years of teaching service within eight years of completing (or otherwise ceasing to be enrolled in) the program for which you received a TEACH Grant, all TEACH Grant funds you received will be converted to Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans) that you must repay in full to the Department, with interest charged from the date of each TEACH Grant disbursement you received.

· If you received a TEACH Grant but did not complete your program of study, within 120 days of ceasing enrollment you must certify that you are employed as a full-time teacher in accordance with the terms and conditions listed in your Agreement to Serve, or that you are not yet employed as a full-time teacher, but you intend to meet the terms and conditions of your service obligation. If you do not meet one of these requirements, your TEACH Grant will be converted to a Direct Unsubsidized Loan.

· If you received a TEACH Grant but did not complete your program of study, within one year of ceasing enrollment you must re-enroll in a TEACH Grant eligible program, begin creditable teaching service or be determined eligible for a suspension of your eight-year obligation period. If you do not meet one of these requirements, your TEACH Grant will be converted to a Direct Unsubsidized Loan.

· If you complete the academic program for which you received a TEACH Grant, you must actively confirm at least once each year that you intend to satisfy your service obligation. If you do not actively confirm your intention, your TEACH Grant will be converted to a Direct Unsubsidized Loan.

· You must maintain qualifying employment within a time-frame that allows you to complete your service obligation within the allotted eight-year period.

· For complete terms and conditions of the TEACH Grant Program, see the TEACH Grant Agreement to Serve (Agreement) that you were required to sign before you received a TEACH Grant.

## SECTION 7: WHERE TO SEND THE COMPLETED CERTIFICATION FORM

**Return the completed form and any attachments to:**

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

**U.S. Department of Education FedLoanServicing**

**P.O. Box 69184 Harrisburg, PA 17106-9184**

or Fax to: 717-720-1628

**1-800-699-2908**

**International: 717-720-1985**

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

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