Minnesota Teacher Shortage Loan Repayment Program Application




You must have read the program description in order to proceed with this application.

Applicant Information









(format: 999999999)



-





(format: 55406 or 554061234)




(optional)



During the 2016-2017 Academic Year, I held a teaching license issued by the licensing division in the Minnesota Department of Education on behalf of the Board of Teaching






to select multiple options:

  • Windows: hold down the control (ctrl) button
  • Mac: hold down the command button



During the 2016-2017 Academic Year, I did not provide classroom instruction under a variance or special permission in any of the license fields listed above




If you are married, subtract any income from working listed for your spouse in 2016.
(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



(You will be asked to provide your federal tax documents verifying this information.)


Are you in default on an educational loan?


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
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00


Applicant Certification

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

  • My teaching license may be suspended or revoked under section 122A.20;
  • I may be disciplined by my employing school district; and
  • I may be required to repay the total amount of the loan forgiveness I received under this program, plus interest at a rate established under section 270C.40.

(type name):    Date: 6/23/2017





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 Teacher Shortage 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.