Teacher Loan Forgiveness Application

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OMB No. 1845-0059
Form Approved
TEACHER LOAN FORGIVENESS APPLICATION
Exp. Date 05/31/2014
William D. Ford Federal Direct Loan Program/Federal Family Education Loan Program
You may qualify for loan forgiveness only if you had no outstanding balance on a William D. Ford Federal Direct Loan (Direct Loan) Program loan or a Federal Family
Education Loan (FFEL) Program loan on October 1, 1998, or had no outstanding balance on a Direct Loan or FFEL program 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 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.
TLFA
SECTION 1: BORROWER IDENTIFICATION
Please enter or correct the following information.
-
-
SSN
Name
Address
City, State, Zip Code
(
)
Telephone - Home
(
)
Telephone - Other
E-mail (optional)
SECTION 2: LOAN FORGIVENESS REQUEST, PREVIOUS LOAN FORGIVENESS INFORMATION, UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION
The borrower must complete this section.
Before completing this section, carefully read the entire form, including the general information and instructions, terms and conditions, definitions, and eligibility requirements in Sections 4
through 8. Information provided in this section may be subject to verification.
Loan Forgiveness Request
I request forgiveness on my Direct Loan and/or FFEL program loan(s) based on my employment as a full-time teacher at an elementary or secondary school or for an educational service agency for at
least five consecutive, complete academic years. (Note: School librarians, guidance counselors, and other administrative staff are not considered teachers for the purposes of this loan forgiveness
program.)
During the period that qualifies me for loan forgiveness, I taught (check one)
at an eligible elementary school
at an eligible secondary school
for an eligible educational service agency and
I was (check one):
1.
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 demonstrated
knowledge and teaching skills in the content areas of the elementary school curriculum (loan forgiveness of up to $17,500).
2.
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 of up to $17,500).
3.
A full-time highly qualified mathematics teacher for secondary school students (loan forgiveness of up to $17,500).
4.
A full-time highly qualified science teacher for secondary school students (loan forgiveness of up to $17,500).
5.
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).
6.
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-time highly
qualified elementary education teacher (loan forgiveness of up to $5,000).
Previous Loan Forgiveness Information
Check one of the boxes below:
I have not previously applied for or received forgiveness on my Direct Loan and/or FFEL program loan(s) under this Teacher Loan Forgiveness Program.
I have applied for or received forgiveness on my Direct Loan and/or FFEL program loan(s) 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/Web Site
Forgiveness Amount $
Understandings, Certifications, and Authorization
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) making regular payments may reduce the amount of
my loan forgiveness; (3) if 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) any
unpaid interest that accrues during each of these forbearance periods 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 terms and conditions in Section 5 and the definitions in Sections 6 and 7; and (3) I
meet eligibility requirements for teacher loan forgiveness as explained in Section 8.
I authorize the entity to which I submit this request (i.e., the school, the lender, the guaranty agency, the U.S. Department of Education, and their respective agents and 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 prerecorded voice or text messages.
Borrower’s Signature
Today’s Date (mm-dd-yyyy)
SECTION 3: CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION
The chief administrative officer (see definition in Section 6) must complete this section.
Before completing this section, carefully 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 form 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. 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 and taught full time for consecutive, complete academic year(s) from ____________________
(mm-dd-yyyy) to ____________________ (mm-dd-yyyy) at one or more eligible Title I schools or educational service agencies in the capacity that the borrower has indicated in Section 2.
Check here if this is a school operated by the Bureau of Indian Education (BIE) or operated on
Name of School or Educational Service Agency (not school district)
an Indian reservation by an Indian tribal group under contract with the BIE.
School or Educational Service Agency Address (Street, City, State, Zip Code)
County
(
)
Chief Administrative Officer’s Name and Title (Printed)
Telephone
Chief Administrative Officer’s Signature
Today’s Date (mm-dd-yyyy)
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