Fillable 2020 Application Data Verification Form and Checklist (Minnesota Department of Revenue)

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2020 Application Data Verification Form and Checklist (Minnesota Department of Revenue)

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The 2020 Application Data Verification Form and Checklist (Minnesota Department of Revenue) form is 3 pages long and contains:

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  • 28 check-boxes
  • 35 other fields

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Revised: Feb 2020
2020 Application Data Verification Form and Checklist
Minnesota Teacher Shortage Student Loan Repayment Program
SECTION 1: APPLICANT INFORMATION
Name
Address
City
State
ZIP Code
File Folder Number (Listed on Educator’s License)
Phone Number
SECTION 2: APPLICANT CERTIFICATION (check boxes)
I certify that the information provided on and attached to these forms are true and correct and I promise to
provide additional documentation if requested.
I understand the information provided on these forms is used to establish eligibility for the Minnesota
Teacher Shortage Loan Repayment program
I understand if I give false or misleading information on these forms, I may:
have my teaching license suspended or revoked under Minnesota Statutes section 122A.20; or
be disciplined by my employing school district; or
be required to repay the total amount of the loan repayment I have received under this program, plus
interest at a rate established under section Minnesota Statutes 270C.40.
Applicant Signature
Date (month, day, year)
SECTION 3: APPLICATION DATA VERIFICATION PACKET CHECKLIST
Please ensure the following forms are completed and returned to the Minnesota Office of Higher Education
prior to the application verification deadline of November 27th, 2020:
Employment Verification Form (included with this document)
Section 1 completed and signed by APPLICANT
Section 2 completed and signed by EMPLOYER
Qualified Education Debt Verification
Submit copies of all current qualified student loan statements to verify the total qualified student
loan debt listed on original application
Copy of 2019 Federal Income Tax Form 1040
Do NOT submit your entire tax return packet
Include your 2019 W2s and other income/wage documents
If married and filing jointly, provide any tax forms that would indicate additional income (example:
personal business, rental property)
If married and filing separately, submit both your and your spouse’s tax forms
If applicant has not filed yet, provide copy of Extension Form 4868, W2s, and other income/wage
documents
Federal W-9 Form
If you have not previously completed a Federal W-9 for purposes of this program and are selected
for an award, this form is required by the State of Minnesota in order for you to receive a payment.
If you have a name or address change, this form is required
Mail:
Fax:
MN Office of Higher Education/TSLRP, 1450 Energy Park Drive, Suite 350, St. Paul, Minnesota 55108
(651) 797-1636 ATTN: TSLRP
Revised: May 2020
2020 Employment Verification Form
Minnesota Teacher Shortage Student Loan Repayment Program
SECTION 1: APPLICANT RELEASE of INFORMATION
Name
Address
City
ZIP Code
School Name
School District Name & Number
I authorize the above named school or school district to provide employment information requested by the
Minnesota Office of Higher Education in conjunction with the Teacher Shortage Loan Repayment Program
Applicant Signature
Date (month, day, year)
SECTION 2: EMPLOYER
The above named employee has applied for the Teacher Shortage Loan Repayment Program. Please complete the
following section regarding the applicant’s employment dates, school, and teaching assignment during the 2019-2020
academic year. *Then, return the completed form to the applicant/employee.
School Name
School District Name & Number
During 2019-2020 academic year, applicant was fully licensed (e.g. not providing classroom instruction using a
Variance and/or Special Permission) by the Minnesota Professional Educator Licensing and Standards Board (PELSB)
and employed by a MN school district.
Yes No
List all license titles and numbers for which applicant was
fully licensed and provided classroom instruction:
Check all boxes that correspond for when
applicant provided classroom instruction:
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
☐ Fall ’19 ☐ Spring ’20 ☐ Summer ‘20
I certify the information provided above is true and complete to the best of my knowledge.
Signature of Authorized Official (designated by school or district)
Date (month, day, year)
Print Name
Title
Email Address
Telephone Number
Mail:
Fax:
MN Office of Higher Education/TSLRP, 1450 Energy Park Drive, Suite 350, St. Paul, Minnesota 55108
(651) 797-1636 ATTN: TSLRP
Revised: May 2020
2020 Qualified Education Debt Verification
Minnesota Teacher Shortage Student Loan Repayment Program
SECTION 1: APPLICANT
Name:
SECTION 2: QUALIFIED STUDENT LOAN INFORMATION
ATTACH to this form the most current statements for all qualified student loans
A Qualified Student Loan is a government, commercial, or foundation loan for actual costs paid for
tuition and reasonable educational and living expenses related to a teacher's preparation or further
education. This includes:
Direct/Stafford Subsidized and Unsubsidized Loans
Federal Family Education Loan (FFEL) Program Loans
Federal Perkins Loans
Minnesota SELF Loans
Other federal or state student loans
Private or commercial student loans
Consolidation loan that combined federal and/or private student loans
Parent PLUS loans made under the FFEL and Direct programs to parents of dependent undergraduate
students and Federal Consolidation Loans and Direct Consolidation Loans that repaid a parent PLUS loan
are disqualified.
Mail:
Fax:
MN Office of Higher Education/TSLRP, 1450 Energy Park Drive, Suite 350, St. Paul, Minnesota 55108
(651) 797-1636 ATTN: TSLRP
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2020 Application Data Verification Form and Checklist (Minnesota Department of Revenue)

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Completed 23 October 2020

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