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OMB No. 1840-0753

Expiration Date: XX/XX/XXXX

Teacher Quality Enhancement Program

Title II, Higher Education Act

Verification of Teaching Obligation

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

a scholarship provided under the Teacher Quality Enhancement Program (TQE) to attend a teacher preparation 

program. As a condition of that scholarship, within six months of completing the program, the individual must 

begin teaching in a high-need school, as that term is defined in Section II, Part C of this form. The individual 

must continue teaching in a high-need school for a period equivalent to the length of time for which he or she 

received the scholarship. The U. S. Department of Education (Department) needs the information identified in 

this document so that it can confirm that the individual has fulfilled this service obligation. 

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

the beginning of the school year, and within seven days of receipt for individuals who begin teaching at other 

times. The Department needs to obtain the information only once during the school year.

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

your school district (Parts A1, A2, A3, A4, and Part B) within seven days of the end of the school year. If the 

individual teaches during the summer (or intersession period if the school district operates a year-round 

program) in a high-need school, we ask that you furnish the information in Part A5 within seven days of the

end of the summer session. Please also include any changes in the name, address, telephone number, fax 

number, or e-mail address of the school district’s reporting official that was previously provided in Section I.

Please mail this completed form to: 

U.S. Department of Education

Office of Postsecondary Education

Teacher Quality Enhancement Program

1990 K Street N.W., 7th floor

Washington, DC 20006-8526 

Thank you for your assistance.
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I. Scholarship Recipient / Teacher Information

Name: ____________________________________________________________________________

Permanent Address: _________________________________________________________________

City, State, Zip Code: ________________________________________________________________

Permanent Telephone Number: ________________________________________________________

Permanent E-Mail _________________________________________

Alternate Address: _________________________________________

City, State, Zip Code: _________________________________________

Alternate Telephone Number: _________________________________________

Alternate E-Mail: _________________________________________

Social Security Number: _____________________________________________________________

Date of Birth: ______________________________________________________________________

Institution that Provided your Scholarship Assistance: _______________________________________

II. School District / School Information

Part A.

School District: ____________________________________________________________________

Address: _________________________________________________________________________

Name of District Official Providing this Information: ________________________________________ 

Title of District Official Providing this Information: _________________________________________

Telephone Number: _________________________________________________________

Fax Number: _________________________ E-Mail: _______________________________

_________________________________ has been employed by the school district as a teacher 

(Name of Teacher)

at _____________________________________________________________________________ 

(School Name)
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 since the beginning of this school year /  beginning ____ weeks after the school year began.

Teaching Start Date: _________________________________________

Part B.

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

 full-time  part-time

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

Part C.

 

To retain his/her financial assistance as a scholarship, _________________________________________

(School Name)

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

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

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

 b.  The school is otherwise eligible, without need of a waiver, to operate as a schoolwide program under 

Title I of the Elementary and Secondary Education Act.

2.  34 percent or more of the school’s academic classroom teachers do not have a major, minor, or 

significant course work in their main assignment field.

3.  34 percent or more of the main assignment faculty in two of the core-subject departments do not have 

a major, minor or significant work in their main assigned field.

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

three school years.

NOTE: If none of these categories applies to the school in which the individual is teaching, please 

notify the individual immediately. He or she is at risk of becoming legally responsible for repayment of 

the full amount of his/her scholarship.

Questions / Comments: _______________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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

Signature of School District Official Date

_________________________________________ _____________________________

Name of School District Official Title 

* Note: Please provide original signature. Do not use rubber stamp.
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III. Confirmation of School-Year /Summer Employment 

(To be completed within seven days of the end of the school year or summer / intersession period. Please 

submit this to the U.S. Department of Education along with the previously completed SECTIONS I and 

II.)

Part A.

_______________________________________________ 

 (Name of Teacher)

1.  Continued to teach at: _______________________________________________________ 

(School Name)

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

year. 

2.  Became a teacher at another school, ___________________________________________,

 (School Name)

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

 (Date)

previously reported. This is a high-need school because it meets the criterion in Box ____ in Section 

II.C of this document.

3.  Teaching End Date: _________________________________________

4.  Number of semesters Scholarship Recipient/Teacher taught: ____________________________

(Include summer teaching assignments in determining total semesters taught).

5.  ____ Taught this summer / intersession period at: 

__________________________________________________.

(School Name)

This is a high-need school because it meets the criterion in Box __ in Part II.C of this document. 

The individual taught at this school from ______________________ to ____________________.

(Date) (Date)

Part B.

If neither 1 nor 2 of Part A is true. Please explain the change of the individual’s employment status 

from what the school district reported in Section II. If applicable, please also provide the date on which 

the individual no longer was employed by the school district or worked in a high-need school. 

________________________________________________________________________________
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________________________________________________________________________________

________________________________________________________________________________

Questions / Comments: ____________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

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

(Name of Teacher)

_________________________________________ _________________________

Signature of School District Official * Date

_________________________________________ _________________________

Name of School District Official Title

* Original signature required. Do not use stamp.
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Privacy Act Notice

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you. The authority 

for collecting the requested information from and about you is Title II, Section 204(e) of the Higher Education 

Act of 1965, as amended by the 1998 Higher Education Amendments, and 31 U.S.C. Chapter 37. We request 

your Social Security Number (SSN) under this authority in order to accurately track your records and to 

differentiate your teaching and financial obligation from other program participants who may have the same 

name as you. You are advised that your participation in the Teacher Quality Enhancement Grants scholarship 

program is voluntary and that giving us your SSN is voluntary, but you must provide the requested information, 

including your SSN, to participate. The information will be used to ensure that recipients of scholarships 

provided with funds under Title II of the Higher Education Act subsequently: (1) complete a teacher education 

program and teach in a high-need school of a high-need local educational agency for a period of time equivalent 

to the period for which the recipient received scholarship assistance; or (2) repay the amount of the scholarship. 

The information in your records may be disclosed to third parties as authorized under routine uses in the 

appropriate systems of records, either on a case-by-case basis, or, if the Department has complied with the 

computer matching requirements of the Privacy Act, under a computer matching agreement. 

The routine uses of this information include sending the information, in the event of litigation, to the 

Department of Justice (DOJ), a court, adjudicative body, counsel, party, or witness if the disclosure is relevant 

and necessary to the litigation. If this information, either alone or with other information, indicates a potential 

violation of law, we may send it to the appropriate authority for action. We may also send this information to 

law enforcement agencies if the information is relevant to any enforcement, regulatory, investigative, or 

prosecutorial responsibility within the receiving entity’s jurisdiction. We may send information to the 

Department of Treasury and to credit agencies to verify the identity and location of the debtor and to the 

Department of Treasury, collection agencies, and employers of the scholarship recipient in order to service or 

collect on the debt. We may send information to members of Congress if you ask them to help you with 

questions related to this Program. In circumstances involving employment complaints, grievances, or 

disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by 

a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. 

Chapter 71. If necessary for the Department to obtain advice from the DOJ, we can disclose information to the 

DOJ. We may disclose information to the DOJ or the Office of Management and Budget (OMB) to help us 

determine whether the Freedom of Information Act requires the disclosure of particular records. We can 

disclose records to contractors if we contract with an entity to perform functions that require the disclosure of 

the records. Disclosures may also be made to qualified researchers under Privacy Act safeguards. Finally, 

disclosures may be made to OMB as necessary under the requirements of the Credit Reform Act. You must 

provide all of the information requested in order to have your request for tuition reimbursement processed.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a 

collection of information unless such collection displays a valid OMB control number. Public 

reporting burden for this collection of information is estimated to average 30 minutes 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 or retain a 

benefit. The authority for collecting the requested information from and about you is Title II, 

Section 204(e) of the Higher Education Act of 1965, as amended by the 1998 Higher 

Education Amendments, and 31 U.S.C. Chapter 37. We request your Social Security Number 

(SSN) under this authority in order to accurately track your records and to differentiate your 

teaching and financial obligation from other program participants who may have the same 

name as you. You are advised that your participation in the Teacher Quality Enhancement 
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Grants scholarship program is voluntary and that giving us your SSN is voluntary, but you 

must provide the requested information, including your SSN, to participate. 

Send comments regarding the burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden, to the U.S. Department of 

Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or e-mail 

ICDocketMgr@ed.gov and reference the OMB Control Number 1840-0753. Note: Please do 

not return the completed Verification of Teaching Obligation to this address.