Teacher Loan Forgiveness Application
Borrower’s Name ___________________________________ Borrower’s SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
SECTION 3: PREVIOUS LOAN FORGIVENESS INFORMATION (TO BE COMPLETED BY THE BORROWER)
Check one of the boxes below:
I have not previously applied for or received loan forgiveness under this Teacher Loan Forgiveness Program.
I have applied for or received loan forgiveness under this Teacher Loan Forgiveness Program with the loan holder
listed below. (If you check this box, provide the loan holder and forgiveness amount information requested below. If you
have applied for but have not yet received forgiveness, leave "Forgiveness Amount" blank.)
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) a forbearance of principal and accrued interest will be applied on the qualifying loan(s) from the
date my loan holder receives my completed loan forgiveness application through the date the loan forgiveness request
is approved or denied, unless I notify my loan holder that I intend to make regular payments during this period; (2)
making regular payments 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 on these
payments; 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 loan holder to which I submit this request (and its agents or contractors) to contact me regarding my
request or my loan(s), including repayment of my loan(s), at the number that I provide on this form or any future
number that I provide for my cellular telephone or other wireless device using automated telephone dialing equipment
or artificial or prerecorded voice or text messages.
Borrower’s Signature _______________________________________ Today’s Date ___ ___ - ___ ___ - ___ ___ ___ ___
SECTION 5: CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION
TO BE COMPLETED BY THE CHIEF ADMINISTRATIVE OFFICER – SEE DEFINITION IN SECTION 8.
Before completing this section, carefully read Sections 7-10. More than one chief administrative officer's certification
may be required. 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 consecutive, complete academic year(s) at one or more
eligible Title I schools or educational service agencies (ESAs) in the capacity that the applicant has 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 District _______________________________________________County ________________________________
Chief Administrative Officer’s Name and Title (Printed) ____________________________________________________
Chief Administrative Officer’s Signature _________________________________________________________________
Telephone ( _______ ) _______ - _____________ Email (optional) ___________________________________________
Today’s Date (mm-dd-yyyy) ___ ___ - ___ ___ - ___ ___ ___ ___
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