TEACHER LOAN FORGIVENESS APPLICATION OMB No.

1845-0059
William D. Ford Federal Direct Loan (Direct Loan) Program Form Approved
Federal Family Education Loan (FFEL) Program Exp. Date 09/30/2023
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
TLFA 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 Code
Telephone - Primary
Telephone - Alternate
Email (Optional)

SECTION 2: LOAN FORGIVENESS REQUEST (TO BE COMPLETED BY THE BORROWER)

READ SECTIONS 7 - 10 BEFORE COMPLETING THE APPLICATION. The information you provide may be subject to
verification.
I request forgiveness on my Direct Loan and/or FFEL program loans based on my employment as a full-time teacher for at
least five consecutive, complete academic years. During that five-year period, I taught (check all that apply):

at an eligible elementary school at an eligible secondary school for an eligible educational service agency

AND I was (check all that apply):

A highly qualified full-time special education teacher for elementary school children with disabilities (forgiveness of up to
$17,500).

A highly qualified full-time special education teacher for secondary school children with disabilities (forgiveness of up to
$17,500).

A highly qualified full-time mathematics teacher for secondary school students (forgiveness of up to $17,500).

A highly qualified full-time science teacher for secondary school students (forgiveness of up to $17,500).

A highly qualified full-time secondary education teacher, or (only if my teaching service began before 10/30/2004) a full-
time secondary education teacher in a subject area relevant to my academic major (forgiveness of up to $5,000).

A highly qualified full-time elementary education teacher, or (only if my teaching service began before 10/30/2004) 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 (forgiveness of up to $5,000).

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Borrower Name Borrower SSN

SECTION 3: PREVIOUS LOAN FORGIVENESS INFORMATION (TO BE COMPLETED BY THE BORROWER)

Have you previously applied for or received loan forgiveness from a loan holder or servicer other than the loan holder/
servicer to which you are submitting this application for Teacher Loan Forgiveness?
No - Skip to Section 4.
Yes - Check the appropriate box below and provide the requested information.
I applied for loan forgiveness with the loan holder/servicer listed below, but have not yet received forgiveness.
Provide the loan holder/servicer information requested below; leave "Forgiveness Amount" blank.
I applied for and received loan forgiveness with the loan holder/servicer listed below. Provide the loan holder/servicer
and forgiveness amount information requested below.
Loan Holder Name
Telephone or Web Site
Forgiveness Amount $

SECTION 4: UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION (TO BE COMPLETED BY THE BORROWER)

I understand that: (1) my loan holder will apply a forbearance of principal and interest on my qualifying loans from the date
my loan holder receives my completed loan forgiveness application through the date my loan forgiveness request is
approved or denied, unless I notify my loan holder that I want to continue making regular payments during this period; (2) if I
continue making regular payments while my application is being reviewed, this 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 a separate
forbearance to resolve the delinquency; 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 1-3 is true and correct; and (2) I have read and understand the
definitions and terms and conditions in Sections 8-10, and I meet the eligibility requirements for loan forgiveness.
I authorize the entity to which I submit this request and its agents to contact me regarding my request or my loans at any
cellular telephone number that I provide now or in the future using automated telephone dialing equipment or artificial or
prerecorded voice or text messages.

Borrower's Signature Date

SECTION 5: CHIEF ADMINISTRATIVE OFFICER'S (CAO'S) CERTIFICATION (TO BE COMPLETED BY THE CAO)
Carefully read Sections 7-10. Return the completed form to the applicant identified in Section 1.
I certify, to the best of my knowledge and belief, that: (1) the applicant has met the requirements for loan forgiveness as
specified in Sections 8-10, and (2) during the period for which the applicant is seeking forgiveness, the applicant was a
teacher as defined in Sections 8 and 9 and taught full time for one or more consecutive, complete academic years at one or
more eligible Title I schools or educational service agencies (ESAs) in the capacity that the applicant 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 ESA Address (Street, City, State, Zip Code)

School or ESA Website
School District County
CAO's Name and Title (Printed)
CAO's Signature Date

Telephone Email (Optional)

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SECTION 6: WHERE TO SEND THE COMPLETED LOAN FORGIVENESS APPLICATION
Return the completed form and any documentation to: If you need help completing this form, call:
(If no address is shown, return to your loan holder.) (If no information is shown, call your loan holder.)

SECTION 7: INSTRUCTIONS FOR COMPLETING THE APPLICATION

Throughout this application, all references to “the Department” mean the U.S. Department of Education.
Before completing Sections 2-4, carefully read the entire application. Be sure to provide all requested information. Enter your
name and Social Security Number at the top of page 2. Type or print using dark ink. Show dates as mm-dd-yyyy (for example,
show “January 31, 2018” as “01-31-2018”).
The chief administrative officer (CAO) of the school or educational service agency where 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 (ESA) during the same academic year
or during different academic years, a single CAO who has access to employment records that establish your eligibility for loan
forgiveness and is authorized to verify your qualifying employment at each school/ESA may complete Section 5. However, all
of the schools/ESAs must be listed. Otherwise, the CAOs from each school/ESA must certify your eligibility. If you need to list
multiple schools/ESAs or need more than one CAO's certification, the information required in Section 5 may be provided on a
separate piece of paper and submitted with your completed form.
Return the completed application 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 application to each loan holder.

SECTION 8: DEFINITIONS
A teacher is a person who provides direct classroom and procedures, in one or more of the following areas:
teaching or classroom-type teaching in a non-classroom physical development, cognitive development,
setting, including special education teachers (see below). communication development, social or emotional
NOTE: School librarians, guidance counselors, and other development, or adaptive development.
administrative staff are not considered teachers for the Physical education means the development of physical
purposes of this loan forgiveness program. and motor fitness, fundamental motor skills and patterns,
Special education means specially designed and skills in aquatics, dance, and individual and group
instruction, at no cost to parents, to meet the unique needs games and sports (including intramural and lifetime sports),
of a child with a disability (see below), including instruction and includes special physical education, adapted physical
conducted in the classroom, in the home, in hospitals and education, movement education, and motor development.
institutions, and in other settings; and instruction in physical
education (see below). An elementary school is a public or nonprofit private
school that provides elementary education as determined
A child with a disability is a child who needs special
by state law or, if the school is not in a state, by the
education and related services because the child has an
intellectual disability, a hearing impairment (including Department.
deafness), a speech or language impairment, a visual A secondary school is a public or nonprofit private
impairment (including blindness), a serious emotional school that provides secondary education as determined by
disturbance, an orthopedic impairment, autism, a traumatic state law or, if the school is not in a state, by the
brain injury, another health impairment, or a specific Department.
learning disability. For a child age 3 through 9, the term “a An educational service agency is a regional public
child with a disability” may, at the discretion of the state and multiservice agency (not a private organization) authorized
the local educational agency, include a child who needs by state statute to develop, manage, and provide services or
special education and related services because the child is programs to local educational agencies (such as public
experiencing developmental delays, as defined by the state school districts), as defined in section 9101 of the
and as measured by appropriate diagnostic instruments Elementary and Secondary Education Act of 1965, as
amended.
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SECTION 8: DEFINITIONS (CONTINUED)

An academic year is: Direct PLUS Loans, Federal PLUS Loans, and any portion
• One complete school year at the same school or for of a Direct Consolidation Loan or Federal Consolidation
the same educational service agency, or Loan that paid off a PLUS loan are not eligible for
forgiveness.
• Two complete and consecutive half years at The holder of your Direct Loan Program loans is the
different schools or for different educational service Department. The holder of your FFEL Program loans may be
agencies, or a lender, secondary market, guaranty agency, or the
• Two complete and consecutive half years from Department. Your loan holder may use a servicer to handle
different school years at either the same school or billing and other communications related to your loans.
for the same educational service agency or at References to “your loan holder” on this form mean either
different schools or for different educational service your loan holder or your servicer.
agencies. The chief administrative officer (CAO)is the official
Half years do not include summer sessions. Two half who has access to employment records that establish your
years generally fall within a 12-month period. For schools or eligibility for loan forgiveness in accordance with the
educational service agencies that have a year-round requirements explained on this form, and who is authorized
program of instruction, a minimum of nine months is to verify your qualifying employment at a school or by an
considered an academic year. educational service agency. Depending on your employer,
Full time means the standard used by a state in the CAO may be a superintendent, a human resources
defining full-time employment as a teacher. If you teach in official or other school district or educational service agency
more than one school or educational service agency, full official, or a principal or assistant principal.
time is based on the combination of all of your qualifying A forbearance is a period of time during which you are
employment. temporarily not required to make payments or temporarily
Loans that are eligible for forgiveness are: allowed to make smaller payments than previously
scheduled, or an extension of time for making payments.
• Federal Direct Stafford/Ford Loans (Direct You are responsible for any interest that accrues on a loan
Subsidized Loans); during forbearance. If you do not pay the interest that
• Federal Direct Unsubsidized Stafford/Ford Loans accrues on the loan, the interest may be capitalized.
(Direct Unsubsidized Loans); Capitalization is the addition of unpaid interest to the
principal balance of your loan. This will increase the
• Subsidized Federal Stafford Loans; principal and total cost of your loan.

• Unsubsidized Federal Stafford Loans; and

• Any portion of a Federal Direct 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.

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SECTION 9: DEFINITION OF HIGHLY QUALIFIED

PUBLIC SCHOOL TEACHERS A teacher of elementary, middle, or secondary

To be a highly qualified teacher, a teacher of public school students who is not new to the profession also is
elementary or secondary school students or a teacher considered highly qualified if the teacher holds at least a
employed by an educational service agency must: bachelor's degree and:
• Have obtained full state certification as a teacher • Meets the applicable standards of a teacher of
(including certification obtained through alternative elementary, middle, or secondary school students
routes to certification) or passed the state teacher who is new to the profession; or
licensing examination, and hold a license to teach in • Demonstrates competence in all the academic
that state, except that when used with respect to subjects in which the teacher teaches based on a
teaching in a public charter school, the term “highly high objective, uniform state standard of evaluation
qualified teacher” means that the teacher meets the that: (1) is set by the state for both grade
requirements set forth in the state's public charter appropriate academic subject matter knowledge
school law; and and teaching skills; (2) is aligned with challenging
state academic content and student academic
• Not have had certification or licensure requirements
achievement standards and developed in
waived on an emergency, temporary, or provisional
consultation with core content specialists, teachers,
basis.
principals, and school administrators; (3) provides
objective, coherent information about the teacher's
In addition, a teacher of elementary school students
attainment of core content knowledge in the
who is new to the profession also is considered highly
academic subjects in which a teacher teaches; (4) is
qualified if the teacher:
applied uniformly to all teachers in the same
• Holds at least a bachelor's degree; and academic subject and the same grade level
• Has demonstrated, by passing a rigorous state test, throughout the state; (5) takes into consideration,
subject knowledge and teaching skills in reading, but is not based primarily on, the time the teacher
writing, mathematics, and other areas of the basic has been teaching in the academic subject; (6) is
elementary school curriculum (which may consist of made available to the public upon request; and (7)
passing a state-required certification or licensing may involve multiple, objective measures of teacher
test or tests in reading, writing, mathematics, and competency.
other areas of the basic elementary school
PRIVATE SCHOOL TEACHERS
curriculum).
To be a highly qualified teacher, a teacher in a private,
A teacher of middle or secondary school students non-profit elementary or secondary school who is not a
who is new to the profession also is considered highly highly qualified teacher as defined above must satisfy
qualified if the teacher: rigorous subject knowledge and skills tests by taking
• Holds at least a bachelor's degree; and competency tests in applicable grade levels and subject
• Has demonstrated a high level of competency in areas. The competency tests must be recognized by five or
each of the academic subjects in which the teacher more states for the purposes of fulfilling the highly qualified
teaches by: (1) passing a rigorous state academic teacher requirements under section 9101 of the Elementary
subject test in each of the academic subjects in and Secondary Education Act of 1965. The teacher must also
which the teacher teaches (which may consist of a achieve a score on each test that equals or exceeds the
passing level of performance on a state-required average passing score for those states.
certification or licensing test or tests in each of the
academic subjects in which the teacher teaches); or
(2) 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.

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SECTION 10: TERMS AND CONDITIONS

Under the Teacher Loan Forgiveness Program, if you If your school or educational service agency is included
teach full time for five consecutive, complete academic in the TCLI Directory for at least one qualifying year of your
years at certain elementary and secondary schools or for teaching service, but does not qualify for inclusion in the
certain educational service agencies that serve low-income TCLI Directory during subsequent years, your subsequent
families and meet other qualifications, you may be eligible years of teaching at that school or educational service
for forgiveness of up to a combined total of $5,000 or agency may be counted toward the required five years of
$17,500 (as applicable) of principal and interest on your teaching. Any years of teaching before the school or
Direct Loan and/or FFEL program loans. educational service agency qualified for inclusion in the TCLI
To qualify for loan forgiveness, you must not have had Directory may not be counted.
an outstanding balance on a Direct Loan or FFEL program If you were unable to complete a full academic year of
loan on October 1, 1998, or on the date that you obtained a teaching, your absence from teaching for part of the year
Direct Loan or FFEL program loan after October 1, 1998. (including the time needed for you to resume teaching no
You are not eligible to receive forgiveness on a later than the beginning of the next regularly scheduled
defaulted loan unless you have first made satisfactory academic year) will not be considered a break in the
repayment arrangements with the holder of the defaulted required five consecutive, complete academic years of
loan. teaching if ALL of the following requirements are met:
Any loan for which you are seeking forgiveness must • You completed at least one-half of the academic
have been made before the end of your five consecutive, year;
complete academic years of qualifying teaching service. • You were unable to complete the remainder of the
You may not receive benefits through the AmeriCorps academic year: (1) because you returned to
Program under Subtitle D of Title I of the National and postsecondary education, on at least a half-time
Community Service Act of 1990 or loan forgiveness under basis, in an area of study directly related to the
the Direct Loan Public Service Loan Forgiveness Program for performance of the teaching service described
the same period of teaching service for which you receive above; (2) due to a circumstance that is a qualifying
forgiveness under this Teacher Loan Forgiveness Program. reason for leave under the Family and Medical Leave
You must have been employed as a full-time teacher for Act of 1993 (FMLA); or (3) because you were called
five consecutive, complete academic years at an elementary or ordered to active duty status for more than 30
or secondary school or for an educational service agency days as a member of a reserve component of the
that is listed in the Annual Directory of Designated Low- Armed Forces; and
Income Schools for Teacher Cancellation Benefits (TCLI • Your employer considers you to have fulfilled your
Directory). The TCLI Directory is available online at contract requirements for the academic year for the
studentaid.gov/app/tcli.action. If this directory is not purposes of salary increases, tenure, and retirement.
available before May 1 of any year, the previous year's You may qualify for forgiveness based on qualifying
directory may be used. To qualify for inclusion in the TCLI teaching service at any combination of eligible elementary
Directory, a school or educational service agency must: (1) schools, secondary schools, or educational service agencies.
be in a school district that qualifies for funds under Title I of Teaching at an eligible elementary or secondary school
the Elementary and Secondary Education Act of 1965, as may be counted only if at least one of the five years of
amended; and (2) have been selected by the Department teaching was after the 1997 -1998 academic year.
based on a determination that more than 30% of the Teaching for an eligible educational service agency
school's or educational service agency's total enrollment is may be counted only if the consecutive five-year period
made up of children who qualify for services provided under includes qualifying service for an eligible educational
Title I. service agency performed after the 2007 -2008 academic
All elementary and secondary schools operated by the year.
Bureau of Indian Education (BIE) or operated on Indian
reservations by Indian tribal groups under contract with the
BIE qualify as schools serving low-income students.

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SECTION 10: TERMS AND CONDITIONS (CONTINUED)

You may receive up to $5,000 in loan forgiveness if you You are not eligible for forgiveness of more than a
were a highly qualified full-time teacher for elementary or combined total of $5,000 or $17,500 (as applicable) of
secondary school students or (only if your qualifying principal and interest of your Direct Loan and/or FFEL
teaching service began before October 30, 2004) you were program loans. You must repay any loan balance that
(1) a full-time teacher for elementary school students and remains after forgiveness has been granted.
you demonstrated knowledge and teaching skills in Unless you instruct your loan holder otherwise, the
reading, writing, mathematics, and other areas of the forgiveness amount will be applied to your loans in the
elementary school curriculum, or (2) a full-time teacher for following order: (1) Direct Unsubsidized Loans or
secondary school students and you taught in a subject area unsubsidized Federal Stafford Loans, (2) Direct Subsidized
that was relevant to your academic major. Loans or subsidized Federal Stafford Loans, and (3) Direct
You may receive up to $17,500 in loan forgiveness if Unsubsidized Consolidation Loans, Direct Subsidized
you were (1) a highly qualified full-time teacher of Consolidation Loans, or Federal Consolidation Loans.
mathematics or science to secondary school students; or (2) If you are determined to be eligible for loan
a highly qualified full-time special education teacher whose forgiveness under this program, your loan holder will not
primary responsibility was to provide special education to refund any payments that you made or that were made on
children with disabilities, and you taught children with your behalf before the determination of eligibility.
disabilities that corresponded to your area of special If you receive loan forgiveness based on any false,
education training and have demonstrated knowledge and fictitious, or fraudulent statements that you make on this
teaching skills in the content areas of the curriculum that form or on any accompanying documents, you may be
you taught. required to repay the amount forgiven and you may be
subject to civil and criminal penalties under applicable
federal law.

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SECTION 11: IMPORTANT NOTICES

Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. To assist program administrators with tracking refunds
552a) requires that the following notice be provided to you: and cancellations, disclosures may be made to guaranty
The authorities for collecting the requested information agencies, to financial and educational institutions, or to
from and about you are 428(b)(2)(A) et seq. and 451 et seq. of federal or state agencies. To provide a standardized method
the Higher Education Act of 1965, as amended (20 U.S.C. for educational institutions to efficiently submit student
1078(b)(2)(A) et seq. and 20 U.S.C. 1087a et seq.) and the enrollment statuses, disclosures may be made to guaranty
authority for collecting and using your Social Security agencies or to financial and educational institutions. To
Number (SSN) is 484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)). counsel you in repayment efforts, disclosures may be made
Participating in the Federal Family Education Loan (FFEL) to guaranty agencies, to financial and educational
Program or the William D. Ford Federal Direct Loan (Direct institutions, or to federal, state, or local agencies.
Loan) Program and giving us your SSN are voluntary, but In the event of litigation, we may send records to the
you must provide the requested information, including your Department of Justice, a court, adjudicative body, counsel,
SSN, to participate. party, or witness if the disclosure is relevant and necessary
The principal purposes for collecting the information on to the litigation. If this information, either alone or with
this form, including your SSN, are to verify your identity, to other information, indicates a potential violation of law, we
determine your eligibility to receive a loan or a benefit on a may send it to the appropriate authority for action. We may
loan (such as a deferment, forbearance, discharge, or send information to members of Congress if you ask them
forgiveness) under the FFEL and/or Direct Loan Programs, to to help you with federal student aid questions. In
permit the servicing of your loans, and, if it becomes circumstances involving employment complaints,
necessary, to locate you and to collect and report on your grievances, or disciplinary actions, we may disclose relevant
loans if your loans become delinquent or default. We also records to adjudicate or investigate the issues. If provided
use your SSN as an account identifier and to permit you to for by a collective bargaining agreement, we may disclose
access your account information electronically. records to a labor organization recognized under 5 U.S.C.
Chapter 71. Disclosures may be made to qualified
The information in your file may be disclosed, on a case- researchers under Privacy Act safeguards.
by-case basis or under a computer matching program, to
third parties as authorized under routine uses in the Paperwork Reduction Notice. According to the
appropriate systems of records notices. The routine uses of Paperwork Reduction Act of 1995, no persons are required
this information include, but are not limited to, its disclosure to respond to a collection of information unless it displays a
to federal, state, or local agencies, to private parties such as valid OMB control number. The valid OMB control number
relatives, present and former employers, business and for this information collection is 1845-0059. Public reporting
personal associates, to consumer reporting agencies, to burden for this collection of information is estimated to
financial and educational institutions, and to guaranty average 20 minutes (0.33 hours) per response, including
agencies in order to verify your identity, to determine your time for reviewing instructions, searching existing data
eligibility to receive a loan or a benefit on a loan, to permit sources, gathering and maintaining the data needed, and
the servicing or collection of your loans, to enforce the completing and reviewing the information collection. The
terms of the loans, to investigate possible fraud and to verify obligation to respond to this collection is required to obtain
compliance with federal student financial aid program a benefit in accordance with 34 CFR 682.216(f)(1) and 34
regulations, or to locate you if you become delinquent in CFR 685.217(e)(1). If you have comments or concerns
your loan payments or if you default. To provide default rate regarding the status of your individual submission of
calculations, disclosures may be made to guaranty agencies, this form, contact your loan holder at the address shown
to financial and educational institutions, or to state in Section 6.
agencies. To provide financial aid history information,
disclosures may be made to educational institutions.

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