Fill - Free fillable Form Approved: TEACHER LOAN FORGIVENESS FORBEARANCE REQUEST (Educational Establishments) PDF form

TLFF

TEACHER LOAN FORGIVENESS FORBEARANCE REQUEST

William D. Ford Federal Direct Loan (Direct Loan) Program

Federal Family Education Loan (FFEL) Program

OMB No. 1845-0059

Form Approved

Exp. Date 9/30/2020

LS009-XBCR

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 Code

Telephone - Primary

Telephone - Alternate

Email (Optional)

SECTION 2: LOAN FORGIVENESS FORBEARANCE REQUEST

READ SECTIONS 5 - 8 BEFORE COMPLETING THE FORM.

I request forbearance of payments on my eligible Direct Loan and/or FFEL program loans while I am performing qualifying

teaching service as a full-time teacher at an elementary or secondary school or for an educational service agency. During the

period that qualifies me for this forbearance, I am teaching (check one):

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

AND I am (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).

Page 1 of 7

Borrower Name Borrower SSN

SECTION 2: LOAN FORGIVENESS FORBEARANCE REQUEST (CONTINUED)

The current academic year of teaching service for which I am requesting forbearance begins/began on (show dates as mm-

dd-yyyy)

and ends on

I expect to complete my fifth year of qualifying teaching service on

I am/will be performing my qualifying teaching service at the following school or educational service agency (ESA):

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

Telephone

SECTION 3: UNDERSTANDINGS, CERTIFICATIONS, AND AUTHORIZATION

I understand that: (1) this forbearance is granted in twelve-month increments and if I choose to extend it, I must reapply

each year during the five consecutive, complete years of required employment; (2) any unpaid interest that accrues during

the forbearance period may be capitalized, as permitted by law; (3) I qualify for this forbearance only if my loan holder

determines that the expected forgiveness amount for which I am performing qualifying service (up to $5,000 or up to

$17,500, as applicable) will satisfy the anticipated outstanding balance of my eligible loans at the end of my fifth year of

qualifying service; and (4) if I am past due on payments not covered by this forbearance, my loan holder may grant a separate

forbearance to resolve the delinquency on these payments at the time my request is processed.

I certify that: (1) the information I provided in Section 2 is true and correct; (2) after the forbearance ends, I agree to repay

the loans according to the terms of my promissory notes and repayment schedules; (3) I will notify my loan holder

immediately if my teaching service at an eligible school or ESA ends or I otherwise become ineligible for the Teacher Loan

Forgiveness Program; and (4) I meet the eligibility requirements and have read and understand the definitions and terms and

conditions for the Teacher Loan Forgiveness Program in Sections 6-8.

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 4: WHERE TO SEND THE COMPLETED TEACHER LOAN FORGIVENESS FORBEARANCE REQUEST

Return the completed form and any documentation to:

(If no address is shown, return to your loan holder.)

If you need help completing this form, call:

(If no information is shown, call your loan holder.)

Page 2 of 7

U.S. Department of Education / FedLoan Servicing

P.O. Box 69184

Harrisburg, PA 17106-9184

800-699-2908

SECTION 5: INSTRUCTIONS FOR COMPLETING THE FORM

Throughout this form, all references to “the Department” mean the U.S. Department of Education.

Before completing Sections 2 and 3, carefully read the entire form. 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”).

If you do not qualify for this forbearance this year, you may contact your loan holders for other forbearance options or

reapply for this forbearance in a year when you are completing one of your five consecutive, complete years of teaching

service.

Return the completed form to the address shown in Section 4. If you are applying for forbearance of loans that are held

by different loan holders, you must submit a separate form to each loan holder.

SECTION 6: DEFINITIONS

A forbearance is a period of time during which you are

not required to make payments or temporarily allowed to

make smaller payments than previously scheduled, or an

extension of time for making payments. 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.

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.

A teacher is a person who provides 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.

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).

A child with a disability is a child who needs special

education and related services because the child has an

intellectual disability, a hearing impairment (including

deafness), 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 the 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 emotional development, or adaptive

development.

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

Department.

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

Department.

An educational 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 section 9101 of the

Elementary and Secondary Education Act of 1965, as

amended.

Page 3 of 7

SECTION 6: DEFINITIONS (CONTINUED)

An academic year is:

• One complete school year at the same school or for

the same educational service agency, or

• Two complete and consecutive half years at

different schools or for different educational service

agencies, or

• 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 forgiveness 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 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.

Direct PLUS Loans, Federal PLUS Loans, and any portion

of a Direct Consolidation Loan or Federal Consolidation

Loan that paid off a PLUS loan are not eligible for

forgiveness.

The holder of your Direct Loan Program loans is the

Department. The holder of your FFEL Program loans may be

a lender, secondary market, guaranty agency, or the

Department. Your loan holder may use a servicer to handle

billing and other communications related to your loans.

References to “your loan holder” on this form mean either

your loan holder or your servicer.

SECTION 7: DEFINITION OF HIGHLY QUALIFIED

PUBLIC SCHOOL TEACHERS

To be a highly qualified teacher, a teacher of public

elementary or secondary school students or a teacher

employed by an educational service agency 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 profession 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).

Page 4 of 7

SECTION 7: DEFINITION OF HIGHLY QUALIFIED (CONTINUED)

A teacher of middle or secondary school students

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: (1) 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 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.

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 school 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: (1) is set by the state for both grade

appropriate academic subject matter knowledge and

teaching skills; (2) 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;

(3) provides objective, coherent information about the

teacher's attainment of core content knowledge in the

academic subjects in which a teacher teaches; (4) is applied

uniformly to all teachers in the same academic subject and

the same grade level throughout the state; (5) takes into

consideration, but is not based primarily on, the time the

teacher has been teaching in the academic subject; (6) is

made available to the public upon request; and (7) may

involve multiple, objective measures of teacher

competency.

PRIVATE SCHOOL TEACHERS

To be a highly qualified teacher, a teacher in a private,

non-profit elementary or secondary school who is not a

highly qualified teacher as defined above must 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 requirements under section 9101 of the Elementary

and Secondary Education Act of 1965. The teacher must also

achieve a score on each test that equals or exceeds the

average passing score for those states.

SECTION 8: TERMS AND CONDITIONS

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 $5,000 or $17,500 (as applicable) of

principal and interest on your Direct Loan and/or FFEL

program loans.

Your loan holder will not return any payments you make

during the period in which you meet the qualifications for

this loan forgiveness. This forbearance is intended to assist

borrowers who are expected to qualify for forgiveness of

their total loan amounts, by allowing them to not make

payments during this period.

You may qualify for forbearance while performing

qualifying teaching service only if your loan holder

determines that the expected forgiveness amount for which

you are performing the service (up to $5,000 or up to

$17,500, as applicable) will satisfy the anticipated

outstanding balance of your eligible loans at the end of your

fifth year of qualifying teaching service.

To qualify for loan 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.

You are not eligible to receive forgiveness on 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 consecutive,

complete academic years of qualifying teaching service.

Page 5 of 7

SECTION 8: TERMS AND CONDITIONS (CONTINUED)

You may not receive benefits through the AmeriCorps

Program under Subtitle D of Title 1 of the National and

Community Service Act of 1990 or loan forgiveness under

the Direct Loan Public Service Loan Forgiveness Program for

the same period of teaching service for which you receive

forgiveness under this Teacher Loan Forgiveness Program.

You must have been employed as a full-time teacher for

five consecutive, complete academic years at an elementary

or secondary school or for an educational service agency

that is listed in the Annual Directory of Designated Low-

Income Schools for Teacher Cancellation Benefits (TCLI

Directory). The TCLI Directory is available online at

StudentLoans.gov/myDirectLoan/tcli.action

. If this directory

is not available before May 1 of any year, the previous year's

directory may be used. To qualify for inclusion in the TCLI

Directory, a school or educational service agency must: (1)

be in a school district that qualifies for funds under Title I of

the Elementary and Secondary Education Act of 1965, as

amended; and (2) have been selected by the Department

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 1.

All elementary and secondary 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-income students.

If your school or educational service agency is included

in the TCLI Directory for at least one qualifying year of your

teaching service, but does not qualify for inclusion in the

TCLI Directory during subsequent years, your subsequent

years of teaching at that school or educational service

agency may be counted toward the required five years of

teaching. Any years of teaching before the school or

educational service agency qualified for inclusion in the TCLI

Directory may not be counted.

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: (1) you

completed at least one-half of the academic year; (2) your

employer considers you to have fulfilled your contract

requirements for the academic year for the purposes of

salary increases, tenure, and retirement; and (3) you were

unable to complete the academic year because: (A) you

returned to postsecondary education, on at least a half-time

basis, in an area of study directly related to the performance

of the teaching service described above; or (B) you had a

condition covered under the Family and Medical Leave Act

of 1993 (FMLA); or (C) 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.

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 the next regularly scheduled

academic year, is not considered a break in the required five

consecutive, complete academic years.

You may qualify for forgiveness based on qualifying

teaching service at any combination of eligible elementary

schools, secondary schools, or educational service agencies.

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.

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.

You may receive up to $5,000 in loan forgiveness if you

were a highly qualified full-time teacher for elementary or

secondary school students or (only if your qualifying

teaching service began before October 30, 2004) you were

(1) a full-time teacher for elementary school students and

you demonstrated knowledge and teaching skills in

reading, writing, mathematics, and other areas of the

elementary school curriculum, or (2) a full-time teacher for

secondary school students and you taught in a subject area

that was relevant to your academic major.

You may receive up to $17,500 in loan forgiveness if

you were: (1) a highly qualified full-time teacher of

mathematics or science to secondary school students; or (2)

a highly qualified full-time 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 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 for forgiveness of more than a

combined total of $5,000 or $17,500 (as applicable) of

principal and interest of your Direct Loan and/or FFEL

program loans. You must repay any loan balance that

remains after forgiveness has been granted.

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

required to repay the amount forgiven and may be subject

to civil and criminal penalties under applicable federal law.

Page 6 of 7

SECTION 9: IMPORTANT NOTICES

Privacy Act 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 and/or Direct Loan Programs, to

permit the servicing of your loans, and, if it becomes

necessary, to locate you and to collect and report on your

loans if your loans become delinquent or 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, on a case-

by-case basis or under a computer matching program, to

third parties as authorized under routine uses in the

appropriate systems of records notices. The routine uses of

this information include, but are not limited to, its disclosure

to federal, state, or local agencies, to private parties such as

relatives, present and former employers, business and

personal associates, to consumer reporting agencies, to

financial and educational institutions, and to guaranty

agencies 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 loans, to enforce the

terms of the loans, to investigate possible fraud and to verify

compliance with federal student financial aid program

regulations, or to locate you if you become delinquent in

your loan payments or if you default. To provide default rate

calculations, disclosures may be made to guaranty agencies,

to financial and educational institutions, or to state

agencies. To provide financial aid history information,

disclosures may be made to educational institutions.

To assist program administrators with tracking refunds

and cancellations, disclosures may be made to guaranty

agencies, to financial and educational institutions, or to

federal or state agencies. To provide a standardized method

for educational institutions to efficiently submit student

enrollment statuses, disclosures may be made to guaranty

agencies or to financial and educational institutions. To

counsel you in repayment efforts, disclosures may be made

to guaranty agencies, to financial and educational

institutions, or to federal, state, or local agencies.

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. Disclosures may 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 it 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 information collection. The

obligation to respond to this collection is required to obtain

a benefit in accordance with 34 CFR 682.216(e) and 34 CFR

685.217(c)(13). If you have comments or concerns

regarding the status of your individual submission of

this form, contact your loan holder at the address shown

in Section 4.

Page 7 of 7

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