Records Code: XTSP
SECTION 1: TEACH GRANT RECIPIENT IDENTIFICATION Please enter or correct the following information:
and ending
unable to teach to fulfill my service obligation. I have provided any required documentation (as described in Section 7).
B
.
.
.
.
, and I am the
Note: A qualifying exigency (as defined in 29 CFR 825.126) arising out of the fact that your spouse, child, or parent is a covered
military member on active duty (or has been notified of an impending call or order to active duty) in support of a contingency operation
is an additional condition for FMLA leave. If you believe you qualify for a suspension due to a qualifying exigency, carefully review
Section 7 and contact your grant servicer (see Section 8).
that I am or was
For the birth of my child and to care for my newborn child. My child was born on
For the placement of a child for adoption or foster care. This child was placed with me on
To care for my (check one)
spouse
child
or parent
Because of a serious health condition that makes me unable to perform the functions of my job. This condition made me unable to work
beginning
spouse
child parent
or next of kin of the servicemember.
I have a condition that is a qualifying reason for leave under the Family and Medical Leave Act of 1993 (FMLA). (Check the box below to identify
your qualifying FMLA condition and provide the requested information. See Section 6 for more information about the FMLA. If you check this box,
you must also complete Section 3.)
To care for a covered servicemember (as defined in 29 CFR 825.127) with a serious injury or illness. I began caring for this individual on
I request a temporary suspension of the 8-year period for completing my service obligation for the reason checked below. I request the suspension for a 12-
month period to cover the full academic year beginning
TEACH Grant Suspension/Military Discharge Request Form
Teacher Education Assistance for College and Higher Education (TEACH) Grant Program
with a serious health condition. I began caring for this individual on
SSN Name
Address
City
State
Zip
Address Email (Optional)
Telephone-Primary Telephone-Alternate
A
I am/was enrolled in a program of study for which I would be eligible to receive a TEACH Grant (TEACH Grant-eligible program) or in a program
of study that has been determined by a state to satisfy the requirements for certification or licensure to teach in the state's elementary or
secondary schools. (If you check this box you must complete Section 3 and have an authorized official complete Section 4 to confirm your
enrollment.)
SECTION 2: SUSPENSION/MILITARY DISCHARGE REQUEST
Check one:
Before completeing this form, carefully read the entire form, including the instructions, and other information in Sections 4,5,6 and 7. For the Military
Service Suspension/Discharge request, a representative may complete and sign this form on your behalf if you are unable to do so.
Request for Suspension of Service Obligation
C
I am a member of a reserve component of the Armed Forces and have been called to active duty status for more than 30 days, or I am a
member of the National Guard on full-time National Guard duty under a call to active service in connection with a war, military operation, or
national emergency, as defined in Section 6. (If you check this box you must complete Section 3 and have your Commanding or Personnel
Officer complete Section 4, or provide a copy of your military orders as described in the instructions for Section 4.)
D
I have received the maximum 3 years of suspension for qualifying active duty military service, but I am subject to an extended call or order to
active duty status as a member of the Armed Forces of the United States, as defined in Section 6. I request a proportional discharge of my service
obligation, as described in Section 7. (If you check this box you must complete Section 3 and have your Commanding or Personnel Officer complete
Section 4, or provide a copy of your military orders as described in the instructions for Section 4.)
Signature of Recipient or Recipient's Representative
Date:
Printed name of Recipient's Representative (if applicable)
Relationship to Recipient
Address of Recipient's Representative
Telephone
Recipient Name
Recipient SSN
n I understand that:
n I certify that:
(1) My TEACH Grant servicer will not grant this suspension or discharge unless I have completed all applicable sections of this form
and provided any required documentation.
(2) I can receive one 12-month period of suspension of the period for completing my service obligation at a time. I may reapply for another suspension
at the end of the 12-month period if I continue to meet the eligibility requirements. The maximum period for which I may receive a suspension is
three years combined for suspensions based on enrollment in a qualifying program of study or an FMLA condition, and three years for suspension
based on qualifying military service.
(3) My suspension request must be received by TEACH Grant servicer before I am subject to any of the conditions that would cause my TEACH Grant
to be converted to a Direct Unsubsidized Loan as explained in my Agreement to Serve.
(4) By signing this form, I am certifying my intent to fulfill my service obligation, regardless of whether or not my suspension or discharge request
is approved.
(5) If I am granted a discharge of a portion of my TEACH Grant service obligation based on qualifying military service, I am responsible for completing
the remaining period of my service obligation in accordance with the terms and conditions specified in my Agreement to Serve.
(1) the information I have provided on this form is true and correct;
(2) I have read, understand, and meet the eligibility requirements of the suspension or discharge that I have requested, as explained in Sections 2, 6,
and 7; and
(3) I will provide my TEACH Grant servicer with additional documentation, as required, to support my suspension or discharge request.
The recipient's enrollment in a qualifying program of study OR qualifying military service begins/began on
and ends/ended on
.
Request for Military Discharge of Service Obligation
SECTION 3: RECIPIENT UNDERSTANDINGS AND CERTIFICATION
SECTION 4: AUTHORIZED OFFICIAL'S CERTIFICATION
This section must be completed ONLY if item A, C or D is checked in Section 2.
Note: As an alternative to completing this section, for the military suspension/discharge only, separate documentation from the Commanding or
Personnel Officer that includes all of the information requested below may be attached or, a copy of the TEACH Grant recipient's military orders and
military identification may be submitted. The orders must include all information needed to establish the recipient's eligibility for the suspension or
discharge as indicated in Sections 2 and 7, including the period of the qualifying active duty service.
I certify that the TEACH Grant recipient identified in Section 1 is/was enrolled in an eligible program of study or is/was performing qualifying military service that
qualifies the individual for the suspension or discharge indicated in Section 2 and meets the eligibility requirements described in Section 7.
Name of Institution, Military Branch or National Guard Component:
City
State
ZIP
Name & Title of Authorized Official (please print):
Telephone
Date
n For the In-School suspension only (Section 2, Item A):
A TEACH Grant eligible program is a program of study that is designed to prepare an individual to teach as a highly-qualified teacher in a high-
need field and leads to a baccalaureate or master's degree, or is a post-baccalaureate program of study. A two-year program of study that is
acceptable for full credit toward a baccalaureate degree is considered to be a program of study that leads to a baccalaureate degree.
n For the FMLA suspension only (Section 2, Item B):
• Conditions that are qualifying reasons for leave under the Family and Medical Leave Act of 1993 (FMLA) are defined in 29 CFR 825.112 and
include: (1) Birth of a son or daughter, and caring for the newborn child; (2) Placement with you of a son or daughter for adoption or foster care; (3)
Caring for your spouse, son, daughter, or parent with a serious health condition; (4) A serious health condition that makes you unable to perform the
functions of your job; (5) Caring for a covered servicemember with a serious injury or illness if you are the spouse, son, daughter, parent, or next of
kin of the servicemember; and (6) Qualifying exigency arising out of the fact that your spouse, son, daughter, or parent is a covered military member
on active duty (or has been notified of an impending call or order to active duty) in support of a contingency operation. For more detailed information
about these qualifying reasons for leave under the FMLA, go to
http://www.dol.gov/whd/fmla/.
n For the Military Service suspension only (Section 2, Item C):
• An authorized official who may complete Section 4 is your Commanding or Personnel Officer.
• The Armed Forces of the United States means the Army, Navy, Air Force, Marine Corps, and the Coast Guard.
• An authorized official who may complete Section 4 is your Commanding or Personnel Officer.
Full-time National Guard duty means training or other duty, other than inactive duty, performed by a member of the National Guard of the United States
or the Air National Guard of the United States in the member's status as a member of the National Guard of a State or territory, the Commonwealth of
Puerto Rico, or the District of Columbia under section 316, 502, 503, 504, or 505 of title 32 for which the member is entitled to pay from the United States
or for which the member has waived pay from the United States.
Address
n In-school Suspension (Section 2, Item A)
• You must be enrolled in a TEACH grant eligible program of study or in a program of study that has been determined by a state to satisfy
the requirements for certification or licensure to teach in the state's elementary or secondary schools.
• You must have an authorized official complete Section 4 of this form.
• The maximum amount of time you are eligible for this suspension is 3 years. (This is a combined limit with the FMLA suspension)
SECTION 5: INSTRUCTIONS
Type or print using dark ink. Enter dates as month-day-year (mm-dd-yyyy). Use only numbers. Example: January 31, 2013 = 01-31-2013. Include your name and
account number on any documentation that you are required to submit with this form. If you need help completing this form, contact your TEACH Grant servicer.
Return the completed form and any required documentation to the address shown in Section 8.
SECTION 6: DEFINITIONS
A high need field includes: billingual education and English language acquisition; foreign language; mathematics; reading specialist; science;
specila education; and any other field documented as high need by the Federal Government, a State government or an LEA, and approved by the
Department and listed in the Department's annual Teacher Shortage Area Nationwide Listing.
• An authorized official who may complete section 4 is an official of the school where you are/were enrolled as a student in a TEACH Grant-eligible
or in a program of study that has been determined by a state to satisfy the requirements for the certification of licensure to teach in the state's
elementary or secondary schools.
• The reserve components of the Armed Forces are the following: the Army national Guard of the United States, the Army reserve, the Navy Reserve,
the Marine Corps reserve, the Air National Guard of the United States, the Air Force Reserve, and the Coast Guard reserve.
n For the Military Service discharge only (Section 2, Item D):
SECTION 7: ELIGIBILITY REQUIREMENTS FOR SUSPENSION OR MILITARY SERVICE DISCHARGE
Authorized Official's Signature
• You must have a condition that would be a qualifying reason for leave under the FMLA, as defined in Section 6. Note: A “qualifying exigency” related
to a covered service member's active duty status would generally support only a relatively brief period of FMLA leave. To qualify for a suspension of
the period for completing your TEACH Grant service obligation based on this qualifying reason for leave under the FMLA, your exigency must prevent
you from completing an academic year of teaching service. Contact your TEACH Grant servicer if you believe you qualify for a suspension based on a
qualifying exigency.
• You must complete Section 2 by checking the appropriate box to identify the reason for which you would qualify for leave under FMLA and must
provide the requested information for the reason that you check.
n Military Service Suspension
• You must be subject to a call/order to active duty status for more than 30 days as a member of a reserve component of the Armed Forces named in
10 U.S.C. 10101(see Section 6), or service as a member of the National Guard on full-time National Guard duty as defined in 10 U.S.C. 101(d)(5) (see
Section 6) under a call to active service in connection with a war, military operation, or a national emergency.
• You must have your Commanding or Personnel Officer complete Section 4 of this form; or you may provide your TEACH Grant servicer with (1) a
copy of your military orders and copy of your military identification, or (2) a written statement from your Commanding or Personnel Officer certifying (a)
that you are a member of a reserve component of the Armed Forces called or ordered to active duty; (b) the date on which your service began; and if
available, (c) the date on which your service is expected to end.
• The maximum amount of time you are eligible for this suspension is 3 years. If you have exhausted your eligibility for suspension due to military
service but are subject to an extended call or order to active duty status as a member of the Armed Forces of the United Stated, as defined in Section
6, you may request a proportional discharge of your service obligation.
n Military Service Discharge
• You must have received the maximum 3 years of suspension for qualifying active duty military service, and must be subject to an extended call or
order to active duty status as a member of the Armed Forces of the United States, as defined in Section 6. You may qualify for a proportional discharge
of your TEACH Grant service obligation as follows: (1) one-year discharge if a call or order to active duty status is for more than three years, (2) two-
year discharge if a call or order to active duty status is for more than four years, (3) three-year discharge if a call or order to active duty status is for
more than five years, (4) full discharge if a call or order to active duty status is for more than six years.
• You must have your Commanding or Personnel Officer complete Section 4 of this form; or you may provide your TEACH Grant servicer with (1) a copy
of your military orders and a copy of your military identification, or (2) a written statement from your Commanding or Personnel Officer certifying (a) that
you are on active duty with the Armed Forces of the United States as defined in Section 6; (b) the date on which your service began; and (c) the date
on which your service is expected to end.
• If you receive a discharge of a portion of your TEACH Grant service obligation, you remain responsible for completing any portion of the service
obligation that is not discharged.
The maximum amount of time you are eligible for this suspension is 3 years (This is a combined limit with the In-School suspension).
Return completed form and any attachments to:
U.S. Department of Education
P.O. Box 69184
Harrisburg, PA 17106-9184
or Fax to: 717-720-1628
If you need help completing this form, call:
1-800-699-2908
International: 717-720-1985
TDD: 1-800-722-8189
n FMLA Suspension requirements (Section 2, Item B)
SECTION 8: WHERE TO SEND THE COMPLETED SUSPENSION/DISCHARGE REQUEST FORM
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