Minnesota Agricultural Education Loan Repayment Program Application

Check here if you have read the program description.
You must have read the program description in order to proceed with this application.

Applicant Information

File Folder Number

First Name

Middle Initial

Last Name

Please list any previous names, especially if current name is different from what is on your student loans

Date of Birth:

Social Security Number
(format: 999999999)

Phone
-

Mailing Address

City, State

Zip Code
(format: 55406 or 554061234)

Email Address

Re-type Email Address

Indicate the level of agricultural education you completed at a Minnesota college or university (check all that apply):
Undergraduate
Graduate

Please list the Minnesota college or university you earned your agricultural education degree:

During the 2024-2025 Academic Year, I will hold an agricultural education teaching license issued by the Minnesota Professional Educator Licensing and Standard Board (PELSB).
Yes
No

During the 2024-2025 Academic Year, I will sign a service agreement to provide agricultural classroom instruction full-time in the following Minnesota school

If you are unable to find your school district, please type the number and name of your school district

Please list your 2023 Adjusted Gross Income
If you are married, subtract any income from working listed for your spouse in 2023.
(Income from working is the total of all amounts listed on your spouse's W2s plus any income from self-employment.)
Enter whole numbers with no commas.
(You will be asked to provide federal tax documents verifying this information.)

$ .00

Please list the number of individuals in your household. Your household usually includes you, your spouse (if married), and any tax dependents.
(You will be asked to provide your federal tax documents and any other support documentation to verify this information.)

Are you in default on an educational loan?
Yes
No

Current Educational Debt

Do not include:

Any debt of your spouse, if married.
Any debt your parents took out to fund your education.
Loans for which you are not the debtor.
Loans that are currently in default.
Parent Plus loans you borrowed for a dependent child or any consolidated loans that include Parent Plus loans you borrowed for a dependent child.

List how much you owe (principal plus interest) on each type of educational loan today.

Enter whole numbers (no cents) with no commas.

Loans

Loan	Total Principal and Interest Owed Today
Federal Subsidized Stafford FFEL or Direct loans that have not been consolidated	$ .00
Federal Unsubsidized Stafford FFEL or Direct loans that have not been consolidated	$ .00
Federal Perkins loans that have not been consolidated	$ .00
Graduate PLUS loans	$ .00
Consolidated Federal loans which DO NOT include Parent (PLUS) Loans	$ .00
SELF (state of MN Student Educational Loan Fund) loans	$ .00
Private educational loans	$ .00

Applicant Certification

Please check the box next to each statement indicating that you have read and agree to the statement:

Applicant's Signature (type name): Date: 9/7/2024

Notice to Applicants

Section 7(b) of the Federal Privacy Act of 1974 (5 U.S.C. 552a) requires that when any federal, state, or local government agency asks you to disclose your Social Security Account Number, you must be advised whether that disclosure is mandatory or voluntary, by what statutory or other authority the number is solicited, and what uses will be made of it. Accordingly, you are being advised that disclosure of your Social Security number is voluntary.

The Social Security number will be used to verify your identity, and as an identifier of your file in order to record necessary data accurately. As an identifier, the Social Security number is used in the Minnesota Agricultural Education Loan Repayment Program for such purposes as processing the application form, program evaluation, and reporting.

Pursuant to Minnesota Statutes, Sec. 13.04, subd. 2 (2004), you are hereby informed that the information supplied in this application may be used as follows: (1) in the processing and verification of the data supplied to determine your eligibility for this program; and (2) for compilation and analysis of summary data relative to this program. You are not required to provide the information supplied in this application. However, failure to submit requested data may prevent further processing of this application. The information supplied in this application may be shared with other public and private individuals and entities in order to use the information for the purposes specified above.

The Office of Higher Education does not discriminate on the basis of disability in the admission or access to, or treatment or employment, in its programs or activities. This document can be made available in an alternative format to individuals by calling (651) 642-0567.

	I understand and accept the obligation to provide a written report to the Office of Higher Education of any changes in information provided on this application.
	I give permission to the Office of Higher Education to verify the information provided on this application.
	I give permission to my employer to release information regarding my employment as a licensed teacher providing classroom instruction including, but not limited to, the subjects and grade levels in which I am currently providing classroom instruction.
	I certify that the information on this application is true and correct.
	I understand I will be required to provide additional documentation including, but not limited to, documentation of income, qualified educational loan debt and current teaching license.
	I understand that if selected for an award, I will be required to complete a federal W-9 form in order for the repayment award to be disbursed directly to me.
	I understand that if I receive a loan repayment award, I will be required to provide verification that the funds were used to make a payment to one or more qualified education loans within 12 months of receiving the disbursement. My next disbursement will only be disburse to me once I have provided sufficient proof of payment.
	I understand that all awards are subject to the availability of funds.
	I understand the program may use information I provide to participate in this program to evaluate the program.
	I understand that if selected for an award, I will be required to sign a service agreement to provide agricultural instruction full-time at a Minnesota school for the next five years.