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Nelnet - Teacher Loan Forgiveness Application

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TLFA
TEACHER LOAN FORGIVENESS APPLICATION
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
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 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).
Page 1 of 8
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 under this Teacher Loan Forgiveness Program?
Yes - Check the appropriate box below and provide the requested loan holder and forgiveness amount information.
No - Skip to Section 4.
I applied for loan forgiveness with the loan holder listed below, but have not yet received forgiveness. Provide the
loan holder information requested below; leave "Forgiveness Amount" blank.
I applied for and received loan forgiveness with the loan holder listed below. Provide the loan holder 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 1 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)
Page 2 of 8
click to sign
signature
click to edit
dd mmm yyyy
SECTION 6: WHERE TO SEND THE COMPLETED LOAN FORGIVENESS APPLICATION
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.)
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 during the same academic year, the
CAO from one of the schools or educational service agencies may complete Section 5. However, all of the schools and/or
educational service agencies must be listed. If you taught at different schools or for different educational service agencies
during different academic years, the CAOs from all of the schools or educational service agencies must certify your eligibility.
If you need more than one CAO's certification, the additional certifications, containing the information 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
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 8
SECTION 8: 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.
The chief administrative officer (CAO)is the official
who has access to employment records that establish your
eligibility for loan forgiveness in accordance with the
requirements explained on this form, and who is authorized
to verify your qualifying employment at a school or by an
educational service agency. Depending on your employer,
the CAO may be a superintendent, a human resources
official or other school district or educational service agency
official, or a principal or assistant principal.
A forbearance is a period of time during which you are
temporarily 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.
Page 4 of 8
SECTION 9: 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).
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.
Page 5 of 8
SECTION 10: TERMS AND CONDITIONS
Under the Teacher Loan Forgiveness 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.
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.
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 1 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; (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.
Page 6 of 8
SECTION 10: TERMS AND CONDITIONS (CONTINUED)
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.
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.
Unless you instruct your loan holder otherwise, the
forgiveness amount will be applied to your loans in the
following order: (1) Direct Unsubsidized Loans or
unsubsidized Federal Stafford Loans, (2) Direct Subsidized
Loans or subsidized Federal Stafford Loans, and (3) Direct
Unsubsidized Consolidation Loans, Direct Subsidized
Consolidation Loans, or Federal Consolidation Loans.
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.
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 you may be
subject to civil and criminal penalties under applicable
federal law.
Page 7 of 8
SECTION 11: 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(f)(1) and 34
CFR 685.217(e)(1). 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 6.
Page 8 of 8
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Nelnet - Teacher Loan Forgiveness Application

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