Page **1** of **8** 

### TLFA 

## TEACHER LOAN FORGIVENESS APPLICATION **William D. Ford Federal Direct Loan Program Federal Family Education Loan Program**  **[DRAFT 0 3** **/1 0** **/2014]** OMB No. 1845 - 0059 Form Approved Exp. Date xx/xx/xxxx **WARNING:** Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying document is subject to penalties that 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. **Check this box if any of your information has changed.**

SSN Name Address City, State, Zip Telephone – Primary Telephone – Alternate E mail (optional ) ___ ___ ___ - ___ ___ - ___ ___ ___ ___

____________________________________

____________________________________

____________________________________ ( _______ ) _______ - _____________ ( _______ ) _______ - _____________

______________________ ______________ **SECTION 2: LOAN FORGIVENESS REQUEST (TO BE COMPLETED BY THE BORROWER)**  **READ SECTION 7 BEFORE YOU BEGIN COMPLETING THE FORM.**  **The information you provide**  **is subject to verification.**  I request forgiveness o f my Direct Loan and/or FFEL program loan(s) based on my employment as a full -time teacher for at least five consec utive, complete academic years. During the period that qualifies me for loan forgiveness – **( A** **)** I taught (check one) : at an eligible **elementary school** at an eligible **secondary school** for an eligible **educational service agency** and **( B**  **)** I was (check one) : A full -time highly qualified special education teacher for elementary school children with disabilities. The children’s disabilities corresponded to my special education training, and I demonstrat ed knowledge and teaching skills in the content areas of the elementary school curriculum (loan forgiveness of up to $17,500) . A full -time highly qualified special education teacher for secondary school children with disabilities. The children’s disabilities corresponded to my special education training, and I demonstrated knowledge and teaching skills in the content areas of the secondary school curriculum (loan forgiveness o f up to $17,500) . A full -time highly qualified mathematics teacher for secondary school students (loan forgiveness of up to $17,500) . A full -time highly qualified science teacher for secondary school students (loan forgiveness of up to $17,500) . A full -time secondary education teacher in a subject area relevant to my academic major, or a full -time highly qualified secondary education teacher (loan forgiveness of up to $5,000) . A full -time elementary education teacher and I demonstrated knowledge and teaching skills in reading, writing, mathematics, and other areas of the elementary school curriculum, or a full -tim e highly qualified elementary education teacher (loan forgiveness of up to $5,000) .Page **2** of **8 SECTION 3: PREVIOUS LOAN FORGIVENESS INFORMATION (TO BE COMPLETED BY THE BORROWER)**  Check one of the boxes below: I have not previously applied for or received loan forgiveness under this Teacher Loan Forgiveness Program. I have app lied for or received loan forgiveness under this Teacher Loan Forgiveness Program with the loan holder listed below. (If you check this box, provide the loan holder and forgiveness amount information requested below. If you have applied for but have not yet received forgiveness, leave "Forgiveness Amount" blank.) **Loan Holder Name**

_______________________________________________________________________________ **Loan Holder Telephone or Web Site**

________________________________________________________________ _ **Forgiveness Amount** $

_______________________ **SECTION 4: UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION (TO BE COMPLETED BY THE BORROWER) I understand**  that: **(1)** 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 approved or denied, unless I notify my loan holder that I intend to make regular payments during this period; **(2)** m aking regular payments may reduce the amount of my loan forgiveness; **(3)** i f I am past due on payments when this application is processed, my loan holder may grant me a separate forbearance to resolve the delinquency on these payments; and **(4)** a ny unpaid interest that ac crues during each of these forbearance periods may be capitalized. **I certify** that: **(1)** t he information I provided in Sections 1 , 2 and 3 is true and correct; **(2)** I have read and understand the definitions in Sections 8 and 9, and the terms and conditions in Section 10 ; and **(3)** I meet the eligibility requirements for teacher loan forgiveness as explained in Section 1 0 . **I authorize** the loan holder to which I submit this request (and its agents or contractors) to contact me regarding my request or my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future number that I provide for my cellular telephone or other wireless device using automated telephone dialing equipment or artificial or prerecord ed voice or text messages. **Borrower Signature**

_________________________________ _______ **Today’s Date**  ___ ___ - ___ ___ - ___ ___ ___ ___ **SECTION 5 :**  **CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION TO BE COMPLETED BY THE CHIEF ADMINISTRATIVE OFFICER**  **– SEE DEFINITION IN**  **SECTION 8.**  Before completing this section, carefully read Sections 7 through 10 . More than one chief administrative officer's certification may be required. **Return the completed form t o the borrower.**  **I certify**, to the best of my knowledge and belief, that : **(1)** the borrower has met the requirements for loan forgiveness as specified in Sections 6, 7, and 8, and **(2)** during the period for which the borrower is seeking forgiveness, the borrower was a teacher as defined in Section 6 and t aught full time for consecutive, complete academic year(s) at one or more eligible Title I schools or educational service agencies (ESAs) in the capacity that the borrower has indicated in Section 2 from (mm - dd -yyyy) ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ . **School (not school district)**  **or ESA Name** 

_______________________________________ _____ _ ___________________ Check here if this is a 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. **School or ES A**  **Address (Street, City, State, Zip Code)** 

_______________________________________________________ **County**

_______________________________ ___ _______________________________ ___________________________ **Chief Administrative Officer’s Name**  **and Title (Printed)** 

_____________________ _______________________________ **Telephone** ( _______ ) _______ - _____________ **Email (optional)**

___________________________ ________________ **Chief Administrative Officer’s Signature** 

_ __________

______________________________________________________ **Today’s Date (mm**  **- dd**  **- yyyy)**  ___ ___ - ___ ___ - ___ ___ ___ ___Page **3** of **8 SECTION 6: WHERE TO SEND THE COMPLETED**  **TEACHER LOAN FORGIVENESS APPLICATION**  Return the completed form and any required documentation to: (If no address is shown, return to your loan servicer.) If you need help completing this form, call: (If no information is shown, cont act your loan servicer.) **SECTION 7: GENERAL INFORMATION AND INSTRUCTIO NS FOR COMPLETING THE FORM**  You may qualify for loan forgiveness only if you had no outstanding balance on a Direct Loan or FFEL program loan on October 1, 1998, or on the date that you obtained a Direct Loan or FFEL program loan after October 1, 1998. The Teacher Loan Forgiveness Program is intended to encourage individuals to enter and continue in the teaching profession. Under this program, if you teach full time for five consecutive, complete academic years at certain elementary and secondary schools or for certain educational service agencies that serve low- income families and meet other qualifications, you may be eligible for forgiveness of up to a combined total of $17,500 in principal and interest on your Direct Loan and/or FFEL program loans. For complete terms and conditions, definitions, and eligibility requirements, see Sections 8 through 10 . Before completing Section s 2 through 4, carefully read the entire form . Be sure to provide all requested information. Type or print using dark ink. Show d ates as mm - dd -yyyy (for example, show “January 31, 2014” as “01 - 31 - 201 4”). **The chief administrative officer of the school or educational service agency at or for which you performed your qualifying teaching service must complete Section**  **5 .**  If you taught at more than one school or for more than one educational service agency during the same academic year, the chief administrative officer from one of the schools or educational service agencies may complete Section 5 . If you taught at different schools or for different educational service agencies during different academic years, the chief administrative officers from all of the schools or educational service agencies must certify your eligibility. If you need more th an one chief administrative officer's certification, the additional certifications, containing the information in Section 5 , m ay be provided on a separate piece of paper and submitted with your completed form. **Return the completed form to the address shown in Section**  **6 .**  If you are applying for forgiveness of loans that are held by different loan holders, you must submit a separate form to each loan holder. **SECTION 8: DEFINITIONS**  A **teacher** is a person who provid es direct classroom teaching or classroom -type teaching in a non - classroom setting, including special education teachers (see below) . **NOTE:** School librarians, guidance counselors, and other administrative staff are not considered teachers for the purposes of this loan forgiveness program. o **Special education** means specially designed instruction, at no cost to parents, to meet the unique needs of a child with a disability (see below) , including instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings; and instruction in physical education (see below) . o 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 de afness), 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 t he 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 emotionalPage **4** of **8 SECTION 8: DEFINITIONS (CONTINUED)**  developme nt, or adaptive development. o **Physical education** means the development of physical and motor fitness, fundamental motor skills and patterns, and skills in aquatics, dance, and individual and group games and sports (including intramural and lifetime sports), and includes special physical education, adapted physical education, movement education, and motor 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 **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.  An **educa tional service agency**  is a regional public multiservice agency (not a private organization) authorized by state statute to develop, manage, and provide services or programs to local educational agencies (such as public school districts), as defined in sect ion 9101 of the Elementary and Secondary Education Act of 1965, as amended.  An **academic year** is: o One complete school year at the same school or for the same educational service agency, or o Two complete and consecutive half years at different schools or for different educational service agencies, or o Two complete and consecutive half years from different school years at either the same school or for the same educational service agency or at different schools or for different educational service agencies. Half years do not include summer sessions. Two half years generally fall within a 12 - month period. For schools or educational service agencies that have a year- round program of instruction, a minimum of nine months is considered an academic year.  **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 or educational service agency, full time is based on the combination of all of your qualifying employment.  **Loans that are eligible for f orgiveness**  are Federal Direct Stafford/Ford Loans (Direct Subsidized Loans), Federal Direct Unsubsidized Stafford/Ford Loans (Direct Unsubsidized Loans), Subsidized Federal Stafford Loans, Unsubsidized Federal Stafford Loans, and any portion of a Federal D irect Consolidation Loan or Federal Consolidation Loan that paid off an eligible Direct Subsidized Loan, Direct Unsubsidized Loan, Subsidized Federal Stafford Loan, or Unsubsidized Federal Stafford Loan. Direct PLUS Loans, Federal PLUS Loans, and any porti on of a Direct Consolidation Loan or Federal Consolidation Loan that repaid a PLUS loan are not eligible for forgiveness.  The **holder** of a Direct Loan Program loan is the U.S. Department of Education (ED) . The holder of a FFEL Program loan may be a lender, guaranty agency, secondary market, or ED .  The **chief administrative officer** is the official who has access to employment records that establish your eligibility for loan forgiveness in accordance with the requirements explained on this form, and who is authorized to verify your qualifying employment at a school or by an education al service agency. Depending on your employer, the chief administrative officer may be a principal, assistant principal, superintendent, or other school or educational service agency official.  A **forbearance** is a temporary cessation of payments, an extensio n of time for making payments, or temporary acceptance of smaller payments than previously scheduled. You are responsible for any interest that accrues on a loan during forbearance. If you do not pay the interest that accrues on the loan, the interest may be capitalized. o **Capitalization** is the addition of unpaid interest to the principal balance of your loan. This will increase the principal and total cost of your loan.Page **5** of **8 SECTION 9: DEFINITION OF HIGHLY QUALIFIED**  **PUBLIC SCHOOL TEACHE RS**  **( INCLUDING TEACHERS E**  **MPLOYED BY EDUCATION AL SERVICE AGENCIES**  **)** To be a highly qualified teacher, a teacher of public elementary or secondary school students must:  Have obtained full state certification as a teacher (including certification obtained through alternative routes to certification) or passed the state teacher licensing examination, and hold a license to teach in that state, except that when used with respect to teaching in a public charter school, the term “highly qualified teacher” means that the teacher meets the requirements set forth in the state’s public charter school law; and  Not have had certification or licensure requirements waived on an emergency, temporary, or provisional basis. In addition – A **teacher of elementary school students who is new to the profe ssion**  also is considered highly qualified if the teacher:  Holds at least a bachelor’s degree; and  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 **teacher of middle or secondary school stude nts who is new to the profession**  also is considered highly qualified if the teacher:  Holds at least a bachelor’s degree; and  Has demonstrated a high level of competency in each of the academic subjects in which the teacher teaches by: o 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 teache r teaches); or o 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. A **teacher of elementary, middle, or secondary school students who is not new to the profession**  also is considered highly qualified if the teacher holds at least a bachelor’s degree and:  Meets the applicable standards of a teacher of elementary, middle, or secondary sc hool students who is new to the profession; or  Demonstrates competence in all the academic subjects in which the teacher teaches based on a high objective, uniform state standard of evaluation that: o Is set by the state for both grade appropriate academic s ubject matter knowledge and teaching skills; o 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; o Provide s objective, coherent information about the teacher’s attainment of core content knowledge in the academic subjects in which a teacher teaches; o Is applied uniformly to all teachers in the same academic subject and the same grade level throughout the state; o Takes into consideration, but is not based primarily on, the time the teacher has been teaching in the academic subject; o Is made available to the public upon request; and o May involve multiple, objective measures of teacher competency. **PRIVATE SCHOOL TEACH ERS**  To be a highly qualified teacher, a teacher in a private, non - profit elementary or secondary school who is not a highlyPage **6** of **8 SECTION 9: DEFINITION OF HIGHLY QUALIFIED (CONTINUED)**  qualified teacher as defined above must be permitted to a nd satisfy rigorous subject knowledge and skills tests by taking competency tests in applicable grade levels and subject areas. The competency tests must be recognized by five or more states for the purposes of fulfilling the highly qualified teacher requi rements under section 9101 of the Elementary and Secondary Education Act of 1965 . The teacher must also a chieve a score on each test that equals or exceeds the average passing score for those five states. **SECTION 10: TERMS AND CONDITIONS**  To qualify for loa n forgiveness, you must not have had an outstanding balance on a Direct Loan or FFEL program loan on October 1, 1998, or on the date that you obtained a Direct Loan or FFEL program loan after October 1, 1998. This means that if you had an outstanding balan ce on one or more Direct Loan or FFEL program loans on October 1, 1998, or on any Direct Loan or FFEL program loans that you obtained while you had an outstanding balance on a Direct Loan or FFEL program loan made on or before October 1, 1998, you may qual ify for loan forgiveness if you later paid all of those loans in full so that you had no outstanding balance on any Direct Loan or FFEL program loan at the time you obtained a new Direct Loan or FFEL program loan after October 1, 1998.  You are not eligible to receive forgiveness of a defaulted loan unless you have first made satisfactory repayment arrangements with the holder of the defaulted loan.  Any loan for which you are seeking forgiveness must have been made before the end of your five academic years of qualifying teaching service.  You must not have received benefits through the AmeriCorps Program under Subtitle D of Title I of the National and Community Service Act of 1990 or loan forgiveness under the Direct Loan Public Service Loan F orgiveness Program for the same teaching service for which you are seeking forgiveness on your Direct Loan and/or FFEL program loans.  You must have been employed as a full -time teacher for five consecutive, complete academic years at an elementary or secon dary school or for an educational service agency that: o Is in a school district that qualifies for funds under Title I of the Elementary and Secondary Education Act of 1965, as amended; o Has been selected by ED based on a determination that more than 30% of the school’s or educational service agency’s total enrollment is made up of children who qualify for services provided under Title I; and o Is listed in the Annual Directory of Designated Low-Income Schools for Teacher Cancellation Benefits ( available online at www.tcli.ed.gov ) . If this directory is not available before May 1 of any year, the previous year’s directory may be used. If your school or educational service agency meets the above requirements for at least one year of your teaching service, but does not meet these requirements during subsequent years, your subsequent years of teaching at the school or educational service agency may be counted toward the required five years of teaching. **NOTE :**  All elementary and s econdary schools operated by the Bureau of Indian Education (BIE) or operated on Indian reservations by Indian tribal groups under contract with the BIE qualify as schools serving low - inco me students.  You may qualify for forgiveness based on qualifying tea ching service at any combination of eligible elementary schools, secondary schools, or educational service agencies. However: o Teaching at an eligible elementary or secondary school may be counted only if at least one of the five years of teaching was after the 1997– 1998 academic year. o Teaching for an eligible educational service agency may be counted only if the consecutive five -year period includes qualifying service for an eligible educational service agency performed after the 2007–2008 academic year.  If your five consecutive, complete years of qualifying teaching service began **before October 30, 2004** : o You may receive **up to $5,000** in loan forgiveness if you were:Page **7** of **8 SECTION 10: TERMS AND CONDITIONS**  **(CONTINUED)**

 A full -time teacher for elementary school st udents and you demonstrated knowledge and teaching skills in reading, writing, mathematics, and other areas of the elementary school curriculum; or  A full -time teacher for secondary school students and you taught in a subject area that was relevant to your academic major. o You may receive **up to $17,500** in loan forgiveness if you were:  A highly qualified full -time teacher of mathematics or science to secondary school students; or  A highly qualified special education teacher whose primary responsibility was to provide special education to children with disabilities, and you taught 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 taught.  If your five consecutive, complete years of qualifying teaching service began **on or after October 30, 2004** : o You may receive **up to $5,000** in loan forgiveness if you were a highly qualified full -time teacher for elementary or secondary school st udents. o You may receive **up to $17,500** in loan forgiveness if you were:  A highly qualified full -time teacher of mathematics or science to secondary school students; or  A highly qualified special education teacher whose primary responsibility was to provide special education to children with disabilities, and you taught 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 taug ht.  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: o You completed at least one - half of the academic year; and o Your employer considers you to have fulfilled your contract requirements for the academic year for the purposes of salary increases, tenure, and retirement; and o You were unable to complete the academic year because:  You returned to postsecondary education, on at least a half-time basis, in a n area of study directly related to the performance of the teaching service described above; or  You had a condition 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 :**  Absence due to a period of postsecondary education, 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 t he next regularly scheduled academic year, is not considered a break in the required five consecutive years.  If you are determined to be eligible for loan forgiveness under this program, your loan holder will not refund any payments that you made or that were made on your behalf before the determination of eligibility.  You are not eligible to receive forgiveness for more than a combined total of $17,500 of principal and interest of your Direct Loan and/or FFEL program loan(s). You are responsible for repay ing 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) Direct Unsubsidized Loan(s) or unsubsidized Federal Stafford Loan(s), (2) Direct Subsidized Loan(s) or subsidized Federal Stafford Loan(s), and (3) Direct Unsubsidized Consolidation Loan, Direct Subsidized Consolidation Loan, or Federal Consolidation Loan.  If you receive loan forgiveness based on any false, fictitious, or fraudulent statements that you make on this form or on any accompanying documents, you may be subject to civil and criminal penalties under applicable federal law.Page **8** of **8 SECTION 11: IMPORTANT NOTICES**  **PRIVACY ACT DISCLOSU RE 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 othe r federal agencies u nder 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 financi al 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 rep ayment 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 d efault 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 stat us. 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. Dis closures 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 such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1845 - 0059. Public reporting burden for this collection of information is estimated to average 20 minutes (0.33 hours) per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain a benefit in accordance with 34 CFR 682.21 6(f)(1) and 34 CFR 685.217(e)(1) . If you have comments or concerns regarding the status of your individual submission of this form, contact your loan servicer at the address shown in Section 6.