TEACHER LOAN FORGIVENESS APPLICATION

Federal Family Education Loan Program/William D. Ford Federal Direct Loan Program

YOU MAY QUALIFY FOR LOAN FORGIVENESS ONLY IF YOU HAD NO OUTSTANDING BALANCE ON A FEDERAL FAMILY EDUCATION LOAN (FFEL) PROGRAM

LOAN OR A WILLIAM D. FORD FEDERAL DIRECT LOAN (DIRECT LOAN) PROGRAM LOAN ON OCTOBER 1, 1998, OR HAD NO OUTSTANDING BALANCE ON A

FFEL PROGRAM LOAN OR A DIRECT LOAN ON THE DATE YOU OBTAINED A LOAN AFTER OCTOBER 1, 1998.

WARNING: Any person who knowingly makes a false statement or misrepresentation on this application or on any accompanying documents will be subject to

penalties which may include fines, imprisonment or both, under the U.S. Criminal Code and 20 U.S.C. 1097.

SECTION 1: BORROWER IDENTIFICATION

Please enter or correct the following information. 

SSN

Name

Address

City, State, Zip

Telephone - Home ( )

Telephone - Other ( )

E-mail (optional)

SECTION 2: BORROWER’S LOAN FORGIVENESS REQUEST AND CERTIFICATIONS The borrower must complete this section.

Before completing this section, please read the entire application, including the General Information and Instructions, Terms and Conditions, Definitions, and

Eligibility Requirements in Sections 4, 5, 6, 7, and 8 of this form.

■ I request forgiveness of up to $5,000 on my FFEL and/or Direct Loan program loan(s) based on my employment as a teacher in an eligible elementary or secondary

school. During the period that qualifies me for loan forgiveness (check any box that applies to you):

❑ I taught full time in an elementary school and have demonstrated knowledge and teaching skills in reading, writing, mathematics, and other areas of the

elementary school curriculum.

❑ I taught full time in a secondary school in a subject area that is relevant to my academic major.

❑ I taught full time in an elementary or secondary school, and I was a highly qualified elementary or secondary school teacher as defined in Section 7.

■ I request forgiveness of up to $17,500 on my FFEL and/or Direct Loan program loan(s) based on my employment as a teacher in an eligible elementary or secondary

school. During the period that qualifies me for loan forgiveness (check any box that applies to you):

❑ I taught mathematics or science on a full-time basis in a secondary school and I was a highly qualified mathematics or science teacher.

❑ I taught special education on a full-time basis to children with disabilities in either an elementary school or a secondary school and I was a highly qualified

special education teacher. The children’s disabilities correspond to my special education training, and I have demonstrated knowledge and teaching skills in the

content areas of the elementary or secondary school curriculum.

■ Check one of the boxes below.

❑ I have not previously applied for or received forgiveness on my FFEL and/or Direct Loan program loan(s) under this Teacher Loan Forgiveness Program.

❑ I have applied for or received forgiveness on my FFEL and/or Direct Loan program loan(s) under this Teacher Loan Forgiveness Program with the loan holder

listed below. (If you check this box, provide the loan holder information requested below. If you have applied for but have not yet received forgiveness, leave

“Forgiveness Amount” blank.)

Loan Holder Name Loan Holder Telephone Forgiveness Amount

■ Unless I notify my loan holder otherwise, I understand that a forbearance of principal and accrued interest will be applied on the qualifying loan(s) from the date my

loan holder receives my completed loan forgiveness application through the date the loan forgiveness request is either approved or denied. I understand that any

unpaid interest that accrues during the forbearance period may be capitalized.

■ I certify that: (1) The information I provided in Sections 1 and 2 is true and correct; (2) I have read and understand the definitions in Sections 6 and 7 of this form;

and (3) I meet the terms and conditions and eligibility requirements for teacher loan forgiveness as explained in Sections 5 and 8 of this form.

____________________________________________________________________________________________________________________ ____________________________________________

Borrower’s Signature Date

SECTION 3: CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION The Chief Administration Officer must complete this section.

Before completing this section, please read the General Information and Instructions, Definitions, and Eligibility Requirements in Sections 4, 6, 7, and 8. More

than one Chief Administrative Officer’s certification may be required. Return the completed application to the borrower.

I certify, to the best of my knowledge and belief, that the borrower has met the teaching service requirements for loan forgiveness as specified in Sections 6, 7, and 8 of

this form. In addition, I certify that, during the period for which the borrower is seeking forgiveness, the borrower was a teacher as defined in Section 6 of this form

and taught full time for ___ consecutive complete academic year(s) from to

at an eligible Title I school(s) and that the borrower was one of the following — (1) an elementary school teacher who demonstrated knowledge and teaching skills in

reading, writing, mathematics, and other areas of the elementary school curriculum; (2) a secondary school teacher teaching in a subject area that is relevant to the

borrower’s academic major; or (3) a highly qualified elementary or secondary school teacher.

❑ By checking this box, I certify that, during the borrower’s qualifying service, the borrower was a full-time highly qualified elementary or secondary school teacher

who taught mathematics, science, or special education as defined in Sections 6 and 7 of this form.

________________________________________________________________________________________________________________ ____________________________________________

School Name County

________________________________________________________________________________________________________________ _______________ ( ) _____________________________

School Address (Street, City, State, Zip) Telephone

________________________________________________________________________________________________________________

Chief Administrative Officer’s Name and Title (Printed)

________________________________________________________________________________________________________________ ____________________________________________

Chief Administrative Officer’s Signature Date

OMB No. 1845-0059

Form Approved

Exp. Date 11/30/2007

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TLFA

( ) $
SECTION 4: GENERAL INFORMATION AND INSTRUCTIONS

■ The Teacher Loan Forgiveness Program is intended to encourage individuals to enter and continue in the teaching profession. Under this program, individuals who

teach full time for five consecutive complete academic years in certain elementary and secondary schools that serve low-income families and meet other

qualifications may be eligible for forgiveness of up to a combined total of $17,500 in principal and interest on their FFEL and/or Direct Loan program loans. For

complete terms and conditions and eligibility requirements, see Sections 5 and 8.

■ Before completing Section 2, carefully read Sections 5, 6, 7, and 8. Be sure to provide all requested information. Type or print using dark ink. Show dates as MMDD-YYYY (for example, show “January 1, 2006” as “01-01-2006”).

■ The Chief Administrative Officer of the school at which you performed your qualifying teaching service must complete Section 3. If you taught at more than one

school during the same academic year, the Chief Administrative Officer from one of the schools involved may complete Section 3. If you taught at different schools

during different academic years, the Chief Administrative Officers from each of the schools involved must certify your eligibility. If you need more than one Chief

Administrative Officer’s certification, you may provide the additional certifications, containing the information in Section 3, on a separate piece of paper and submit

that information with your completed application.

■ Return the completed application to the address shown in Section 10. If you are applying for forgiveness of loans that are held by different loan holders, you must

submit a separate application to each loan holder.

SECTION 5: TERMS AND CONDITIONS

■ If you are in default on a FFEL and/or Direct Loan program loan(s), you are not eligible for forgiveness of that loan(s) unless you have made satisfactory repayment

arrangements with the holder of the defaulted loan(s).

■ Your loan holder will not refund any payments that you made or that were made on your behalf before you were determined to be eligible for loan forgiveness under

this program.

■ You are not eligible to receive forgiveness for more than a combined total of $17,500 of principal and interest of your FFEL and/or Direct Loan program loan(s). You

are responsible for repaying any loan balance that remains after the forgiveness has been granted.

■ Unless you instruct your loan holder otherwise, the forgiveness amount will be applied to your loans in the following order: (1) unsubsidized Federal Stafford Loan(s)

or Direct Unsubsidized Loan(s), (2) subsidized Federal Stafford Loan(s) or Direct Subsidized Loan(s), and (3) Direct Subsidized Consolidation Loan, Federal

Consolidation Loan, or Direct Unsubsidized Consolidation Loan.

■ If you receive loan forgiveness based on any false, fictitious, or fraudulent statements that you make on this application or on any accompanying documents, you

may be subject to civil and criminal penalties under applicable federal law.

SECTION 6: DEFINITIONS

■ An academic year is:

• one complete school year at the same school, or

• two complete and consecutive half years at different schools, or

• two complete and consecutive half years from different school years at either the same school or different schools.

Half years exclude summer sessions and generally fall within a 12-month period. For schools that have a year-round program of instruction, a minimum of nine

months is considered an academic year.

■ Capitalization is the addition of unpaid interest to the principal balance of a loan. This will increase the principal and total cost of the loan.

■ The Chief Administrative Officer is the official in your school (such as a principal or an assistant principal) who is responsible for supervising your employment as a

teacher and who has access to records relating to your experience and qualifications for teaching.

■ 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.

■ An elementary school is a public or nonprofit private school that provides elementary education as determined by State law or, if the school is not in a State, by the

U.S. Department of Education.

■ A forbearance is a temporary cessation of payments, an extension of time for making payments, or temporary acceptance of smaller payments than previously

scheduled. The borrower is responsible for any interest that accrues on a loan during forbearance. If the borrower does not pay the interest that accrues on the

loan, the interest may be capitalized.

■ Full-time means the standard used by a State in defining full-time employment as a teacher. If you teach in more than one school, full time is based on the

combination of all of your qualifying employment.

■ The holder of a FFEL Program loan may be a lender, guaranty agency, or the U.S. Department of Education. The holder of a Direct Loan Program loan is the U.S.

Department of Education.

■ Loans that are eligible for forgiveness are Federal Stafford Loans (subsidized and unsubsidized), Federal Direct Stafford/Ford Loans (Direct Subsidized Loans),

Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans), and any portion of a Federal Consolidation Loan or Federal Direct Consolidation Loan

that was used to pay off an eligible or Federal Stafford Loan, Direct Subsidized Loan, or Direct Unsubsidized Loan.

■ A secondary school is a public or nonprofit private school that provides secondary education as determined by State law or, if the school is not in a State, by the

U.S. Department of Education.

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

school librarian or guidance counselor is not considered a teacher for the purposes of this loan forgiveness program.

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SECTION 7: DEFINITION OF HIGHLY QUALIFIED

■ To be a highly qualified teacher a public elementary or secondary school teacher must:

1. Have obtained full State certification as a teacher (including certification obtained through alternative routes to certification) or passed the State teacher licensing

examination, and holds a license to teach in that State, except that when used with respect to any teacher teaching in a public charter school, the term means that

the teacher meets the requirements set forth in the State’s public charter school law; and

2. Have not had certification or licensure requirements waived on an emergency, temporary, or provisional basis.

In addition—

■ An elementary school teacher who is new to the profession is highly qualified if the teacher also:

1. Holds at least a bachelor’s degree; and

2. Has 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).

■ A middle or secondary school teacher who is new to the profession is highly qualified if the teacher also:

1. Holds at least a bachelor’s degree, and

2. Has demonstrated a high level of competency in each of the academic subjects in which the teacher teaches by—

• Passing a rigorous State academic subject test in each of the academic subjects in which the teacher teaches (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 the teacher teaches); or

• Successful completion, in each of the academic subjects in which the teacher teaches, of an academic major, a graduate degree, coursework equivalent to an

undergraduate academic major, or advanced certification or credentialing.

■ An elementary, middle, or secondary school teacher who is not new to the profession is highly qualified if the teacher also:

1. Holds at least a bachelor’s degree; and

2. Meets the applicable standards of an elementary, middle, or secondary school teacher who is new to the profession; or

3. Demonstrates competence in all the academic subjects in which the teacher teaches based on a high 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;

• Provides objective, coherent information about the teacher’s attainment of core content knowledge in the academic subjects in which a teacher teaches;

• 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 the teacher has been teaching in the academic subject;

• Is made available to the public upon request; and

• May involve multiple, objective measures of teacher competency.

SECTION 8: ELIGIBILITY REQUIREMENTS

■ To qualify for up to $5,000 loan forgiveness under this program, you must not have had an outstanding balance on a FFEL or Direct Loan program loan as of October

1, 1998, or on the date that you obtained a Direct Loan Program loan or a FFEL Program loan after October 1, 1998. To qualify for the increased amount of loan

forgiveness available for certain mathematics, science, and special education teachers, you must not have had an outstanding balance on a FFEL or Direct Loan

program loan as of October 1, 1998, or on the date that you obtained a Direct Loan or an FFEL Program loan after October 1, 1998 and before October 1, 2005.

■ The loan(s) for which you are seeking forgiveness was made prior to the end of your five academic years of qualifying teaching service.

■ You have not received loan forgiveness benefits through the AmeriCorps Program under Subtitle D of Title I of the National and Community Service Act of 1990 for

the same teaching service for which you are seeking forgiveness on your FFEL and/or Direct Loan program loan(s).

■ You must have been employed as a full-time teacher for five consecutive complete academic years, at least one of which was after the 1997-1998 academic year, in

an elementary or secondary school that—

1. Is in a school district that qualifies for funds under Title I of the Elementary and Secondary Education Act of 1965, as amended;

2. Has been selected by the U.S. Department of Education based on a determination that more than 30 percent of the school’s total enrollment is made up of children

who qualify for services provided under Title I; and

3. Is listed in the Annual Directory of Designated Low-Income Schools for Teacher Cancellation Benefits (See website address at

http://studentaid.ed.gov/PORTALSWebApp/students/english/cancelstaff.jsp). If this directory is not available before May 1 of any year, the previous year’s

directory may be used.

■ If your school meets the above requirements for at least one year of your teaching service, but does not meet these requirements during subsequent years, the

subsequent years of teaching at the school may be counted toward the required five consecutive complete academic years of teaching.

■ If your five consecutive complete years of qualifying teaching service began before October 30,2004:

— You may receive up to $5,000 in loan forgiveness if, as certified by the Chief Administrative Officer of the school where you were employed, you were:

• A full-time elementary school teacher who demonstrated knowledge and teaching skills in reading, writing, mathematics, and other areas of the elementary

school curriculum; or

• A full-time secondary school teacher who taught in a subject area that was relevant to your academic major.

— You may receive up to $17,500 in loan forgiveness if, as certified by the Chief Administrative Officer of the school where you were employed, you were:

• A highly qualified full-time mathematics or science teacher in an eligible secondary school; or

• A highly qualified special education teacher whose primary responsibility was to provide special education to children with disabilities, and you were teaching

children with disabilities that corresponded to your area of special education training and have demonstrated knowledge and teaching skills in the content areas

of the curriculum that you were teaching. 

Page 3 of 4
SECTION 8: ELIGIBILITY REQUIREMENTS (continued)

■ If your five consecutive complete years of qualifying teaching service began on or after October 30, 2004:

— You may receive up to $5,000 in loan forgiveness if you were a highly qualified full-time elementary or secondary school teacher.

— You may receive up to $17,500 in loan forgiveness if, as certified by the Chief Administrative Officer of the school where you were employed, you were:

• A highly qualified full-time mathematics or science teacher in an eligible secondary school; or

• A highly qualified special education teacher whose primary responsibility was to provide special education to children with disabilities, and you were teaching

children with disabilities that corresponded to your area of special education training and have demonstrated knowledge and teaching skills in the content areas

of the curriculum that you were teaching.

■ If you were unable to complete an academic year of teaching, that year may still be counted toward the required five consecutive complete academic years if —

1. You completed at least one-half of the academic year; and

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

3. You were unable to complete the academic year because:

• You returned to postsecondary education, on at least a half-time basis, in an area of study directly related to the performance of the teaching service described

above; or

• You had a condition that is covered under the Family and Medical Leave Act of 1993 (FMLA); or

• You were called or ordered to active duty status for more than 30 days as a member of a reserve component of the Armed Forces.

Note that the period of postsecondary education, absence due to a condition covered under the FMLA, or active duty service, including the time needed for you to

resume teaching no later than the beginning of the next regularly scheduled academic year, does not constitute a break in the required five consecutive complete

years of qualifying teaching service.

SECTION 9: IMPORTANT NOTICES

Privacy Act Disclosure 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 428(b)(2)(A) et seq. and 451 et seq. of the Higher Education Act of 1965, as amended

(20 U.S.C. 1078(b)(2)(A) et seq. and 20 U.S.C. 1087a et seq.) and the authority for collecting and using your Social Security Number (SSN) is 484(a)(4) of the HEA (20

U.S.C. 1091(a)(4)). Participating in the Federal Family Education Loan (FFEL) Program 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 loan or a

benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the FFEL Program and/or Direct Loan Program, to permit the servicing of your

loan(s), and, if it becomes necessary, to locate you and to collect on your loan(s) if your loan(s) becomes 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 to third parties as authorized under routine uses in the appropriate systems of records. The routine uses of this

information include its disclosure to federal, state, or local agencies, to other federal agencies under computer matching programs, to agencies that we authorize to

assist us in administering our loan programs, to private parties such as relatives, present and former employers, business and personal associates, to credit bureau

organizations, to financial and educational institutions, to guaranty agencies, and to contractors in order to verify your identity, to determine your eligibility to receive a

loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to counsel you in repayment efforts, 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, to provide default rate calculations, to provide financial aid history information, to assist program administrators with tracking refunds and cancellations, or to

provide a standardized method for educational institutions efficiently to submit student enrollment status.

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 also be made to qualified researchers under

Privacy Act safeguards.

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 1845-0059. The time required to complete this information

collection is estimated to average 0.33 hours (20 minutes) per response, including the time to review instructions, search existing data resources, gather and maintain

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 application, please write to: U.S. Department of Education, Washington, DC 20202-4651.

If you have questions regarding the status of your individual submission of this application, contact your loan holder (see Section 10).

SECTION 10: WHERE TO SEND THE COMPLETED LOAN FORGIVENESS APPLICATION

Return the completed loan forgiveness application and any attachments to: If you need help completing this application, call:

(If no address is shown, return to your loan holder.) (If no phone number is shown, call your loan holder.)

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