1845-0158_TEACH Cert_30D_2023-09-12

TEACH GRANT CERTIFICATION OF QUALIFYING TEACHING
Teacher Education Assistance for College and Higher Education (TEACH) Grant Program

OMB No. 1845-0158
Form Under Review
Exp. Date XX/XX/XXXX

CRT

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.
GENERAL INFORMATION AND INSTRUCTIONS
NOTE: Throughout this form, the words “we,” “us,” and “our” refer to the U.S. Department of Education or to your TEACH Grant servicer. The word
“Agreement” refers to the Agreement to Serve or Repay that you signed before you received each of your TEACH Grants.
How do I use this form?
As explained in your Agreement, you must complete at least 4 elementary or secondary school years of qualifying teaching service for each
program of study for which you received a TEACH Grant. You must provide us with documentation of each completed year of teaching by
submitting this form.
As further explained in your Agreement, if you do not begin or do not maintain qualifying teaching service within a timeframe that would allow you
to complete your required 4 years of teaching within the 8-year period described in your Agreement, the TEACH Grants you received will be
converted to Direct Unsubsidized Loans that you must repay in full. Upon our request, you must document that you have begun qualifying teaching
service by submitting this form.
How do I complete the form?
•

Before you begin, carefully read the entire form. Print using dark ink.

•

Your name, address, and other information may be preprinted in Section 1. If any of this information is not shown, or if any preprinted
information is incorrect, enter or correct the information on the right side of Section 1. If any of your information has changed since the last
time you reported it to us, check the box in Section 1 to indicate this.

•

Complete Section 2. Be sure to answer all questions.

•

Sign and date the form in Section 3. Enter the date as month-day-year (for example, if you signed the form on August 25, 2024, you would
enter “0 8 - 2 5 - 20 2 4”).

•

Enter your name and Social Security Number (SSN) at the top of page 3, then have the chief administrative officer (CAO) of your school or
educational service agency complete Section 4. If you are certifying a completed year of teaching and you met the requirements for a full
school year of teaching by teaching at different schools or for different educational service agencies during the same school year, the CAO for
each school or educational service agency must complete Section 4. If you need a certification from more than one CAO, an additional copy of
Section 4 is included on page 7 of this form. Be sure to enter your name and SSN at the top of each certification page that you submit. If the
same CAO is authorized to certify your teaching during the same academic year at different schools or for different educational service
agencies (for example, if you taught at different schools within the same school district), the CAO must provide the information requested in
Section 4 for each school or educational service agency.

•

Make sure that all sections are complete, then send us the completed form (including any additional CAO certifications if required) by one of
the following means:
o

Mail the form and any required documentation to the following address:
U.S. Department of Education
MOHELA
633 Spirit Drive
Chesterfield, MO 63005-1243

o

Fax the form to 1-866-222-7060.

o

Upload the form online atmohela.com/uploadDocument.

Who can I contact if I have questions?
The U.S. Department of Education uses a servicer to monitor your progress toward completing your TEACH Grant service obligation, and to answer
any questions you may have about your service obligation. If you change your address, email address, or telephone number, it is very important to
make sure that your TEACH Grant servicer has your current contact information. If you need help completing this form or if you have questions
about the status of your certification after you have submitted the form, contact your TEACH Grant servicer:
MOHELA
1-888-866-4352
International: 636-532-0600
mohela.com
Page 1 of 7 – 30D DRAFT 09/12/2023

TEACH GRANT CERTIFICATION OF COMPLETED TEACHING
SECTION 1: GRANT RECIPIENT INFORMATION
See the instructions on page 1.
SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Name
___________________________________________________
Address ___________________________________________________
City, State, Zip _______________________________________________
Telephone – Primary
( _______ ) _______ - _________________
Telephone – Alternate
( _______ ) _______ - _________________
Email (optional)
___________________________________________
Check this box if you are changing any preprinted information.
SECTION 2: INFORMATION ABOUT YOUR TEACHING SERVICE (TO BE COMPLETED BY THE TEACH GRANT RECIPIENT)
Read the definitions in Section 6 before you complete this section.
1. Did you complete a full school year of teaching or have you begun teaching?
Yes – Continue to Question 2.
No – Do not complete this form; you must have completed a full school year of teaching or must have begun teaching.
2. Were you a full-time teacher or have you begun full-time teaching?
Yes – Continue to Question 3.
No – Do not complete this form; you must teach full-time.
3. Did you teach or have you begun teaching at a low-income school, as defined in Section 6 of this form?
Yes – Continue to Question 4.
No – Do not complete this form; you must teach at a low-income school as defined in Section 6.
4. Did you teach or have you begun teaching more than half of your classes in a high-need field, as defined in Section 6 of this form?
Yes – Continue to Question 5.
No – Do not complete this form; you must teach the majority of your classes in a high-need field as defined in Section 6.
5. Where did you teach or where have you begun teaching? Check all that apply.
at a low-income elementary school
at a low-income secondary school
for a low-income educational service agency (ESA)
6. In what high-need field or fields did you teach or have you begun teaching? Check all that apply.
Bilingual education or English language acquisition
Foreign language
Math
Reading specialist
Science (includes computer science)
Special education
Other high-need field not listed above (this may include a geographic region or grade level with teacher shortages; see the definition of
“high-need field” in Section 6). If you check this box, continue to Question 7. Otherwise, go to Section 3.
7. If you checked “other high-need field not listed above” in Question 6, in what other high-need field did you teach or have you begun teaching?
IMPORTANT: You must identify the other high-need field using the same name under which the field is listed in the Nationwide List (see the
definition of “high-need field” in Section 6).
________________________________________________________________________________________________________________
SECTION 3: YOUR CERTIFICATIONS AND UNDERSTANDINGS (TO BE COMPLETED BY THE TEACH GRANT RECIPIENT)
I certify that (1) the information I have provided on this form is true and correct; (2) I have read and understand the terms and conditions and
definitions in Sections 5 and 6; and (3) upon request, I will provide additional documentation to my TEACH Grant servicer to document my
qualifying teaching service.
IMPORTANT: I understand that (1) under the terms and conditions of my Agreement, any TEACH Grant I received for a program of study will be
converted to a Direct Unsubsidized Loan if I do not begin qualifying teaching or continue to perform qualifying teaching service within a timeframe
that would allow me to complete my required 4 years of teaching within the 8-year period required by my Agreement; and (2) if any TEACH Grant
that I received is converted to a Direct Unsubsidized Loan, I must repay that loan in full, with interest charged from the date of each TEACH Grant
disbursement.
Grant Recipient’s Signature _________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

Page 2 of 7
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

Grant Recipient’s Name _______________________________________________________________ SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
SECTION 4: CHIEF ADMINISTRATIVE OFFICER’S (CAO’S) CERTIFICATION
Read the definitions in Section 6 before completing this section. Be sure to sign and date the form at the bottom of this page. Return the form to
the grant recipient.
1. What is the name of the school or educational service agency (ESA) where the grant recipient taught or is currently teaching? Enter the name
and other information requested below, then continue to Question 2.
Note: If the grant recipient met the requirements for a full school year of teaching by teaching at different schools or for different ESAs and
you are authorized to certify the recipient’s teaching service at each school or ESA (for example, if the recipient taught at different schools
within the same school district), provide all information requested below for each school or ESA. Attach additional pages if necessary; include
all information requested in this section.
School (not school district) or ESA Name __________________________________________________________________________________
Check here if this is a school or ESA 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 ______________________
2.

3.

4.

5.

6.
7.
8.

Was the grant recipient a full-time teacher who met all state certification requirements for teaching (which may include meeting the
requirements through certification obtained through alternate routes to teaching) during the school year(s) of teaching that you are being
asked to certify?
Yes – Continue to Question 3.
No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.
Were more than half of the classes that the grant recipient taught/teaches in the high-need field(s) indicated by the grant recipient in Section
2 (this may include a geographic region or grade level with teacher shortages; see the definition of “high-need field” in Section 6)?
Yes – Continue to Question 4.
No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.
Has the grant recipient met their contractual requirements (for purposes of salary increases, tenure, and retirement) for a full school year of
teaching, and has that school year ended?
Yes – Continue to Question 5.
No – Skip to Question 8.
Check the box below that describes how the grant recipient completed a full school year of teaching, then follow the instructions for the box
that you check. Check only one box.
The grant recipient completed a full school year of teaching during one school year at the same school or for the same ESA. Continue to
Question 6 and identify the school year.
The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years within the same
school year at different schools or for different ESAs. Continue to Question 6 and identify the school year.
The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years of teaching during
different school years at either the same school or for the same ESA or at different schools or for different ESAs. Skip to Question 7 and
identify the school year.
The grant recipient taught for the full 20___ ___ – 20___ ___ school year.
The grant recipient taught for the second half of the 20___ ___ – 20___ ___ school year and for first half of the 20___ ___ – 20___ ___ school
year.
The grant recipient has begun teaching for the 20___ ___ school year, but has not yet completed a full school year of teaching.

I certify that the information I have provided above about the TEACH Grant recipient’s teaching service is true and correct.
CAO’s Name _____________________________________________________________________________________________________________
CAO’S Title (printed) ______________________________________________________________________________________________________
Telephone ( _______ ) _______ - _____________ Email _________________________________________________________________________
CAO’s Signature ____________________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

Page 3 of 7
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

SECTION 5: TERMS AND CONDITIONS OF YOUR TEACH GRANT SERVICE OBLIGATION
For each program of study for which you received a TEACH Grant, you
must complete a service obligation by teaching full-time for a total of at
least 4 elementary or secondary school years (1) at a school or
educational service agency serving low-income students; and (2) in a
high-need field. In addition, you must meet all state certification
requirements for teaching in the state where you teach (which may
include meeting the requirements through certification obtained
through alternate routes to teaching).
You must complete the 4 years of teaching within 8 years after you
cease to be enrolled at the postsecondary institution where you
received your TEACH Grants. You must provide us with documentation
of each completed school year of teaching. When requested, you must
provide us with other documentation showing that you are meeting the
terms and conditions of your service obligation.

If you do not begin qualifying teaching or continue to perform qualifying
teaching service within a timeframe that would allow you to complete
the required 4-year service obligation for a program of study within the
8-year period required by your Agreement, any TEACH Grant you
received for that program of study will be converted to a Direct
Unsubsidized Loan that you must repay in full, with interest charged
from the date of each TEACH Grant disbursement you received. Any
TEACH Grant you received will also be converted to a Direct
Unsubsidized Loan if you ask us to convert your TEACH Grant to a loan
because you have decided not to teach in an eligible school or field, or
for any other reason. For the complete terms and conditions of your
TEACH Grant service obligation, refer to your Agreement.

SECTION 6: DEFINITIONS
Chief administrative officer
The chief administrative officer (CAO) who may complete Section 4 is
the official who has access to employment records that establish that
your teaching service meets the terms and conditions of your TEACH
Grant Agreement, as described in Section 5, and who is authorized to
verify your qualifying teaching service. Depending on your employer, the
chief administrative officer may be a superintendent, a human resources
official or other school district or educational service agency official, or a
principal or assistant principal.
Educational service agency
An educational service agency (ESA) 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
(ESEA).
Elementary school
An elementary school is a public or nonprofit private school, including a
public elementary charter school, that provides elementary education,
as determined under state law.

geographic region of a state or a specific grade level designated as
having a shortage of teachers.
To satisfy your TEACH Grant service obligation by teaching in a highneed field that is listed in the Nationwide List, the field must be listed for
the state where you are teaching at the time you begin teaching in that
field (even if the field later loses its high-need designation), or it must
have been listed for the state where you are teaching at time you signed
your Agreement or received a TEACH Grant (even if the field loses its
high-need designation before you begin teaching in that field).
Low-income school
A low-income school is an elementary school, secondary school, or
educational service agency (ESA) that is listed in the U.S. Department of
Education’s Teacher Cancellation Low-Income Directory (TCLI Directory)
at https://studentloans.gov/myDirectLoan/tcli.action. All elementary
and secondary schools or educational service agencies operated by the
U.S. Department of the Interior’s Bureau of Indian Education (BIE) or
operated on Indian reservations by Indian tribal groups under contract
or grant with the BIE qualify as low-income schools, even if they are not
listed in the TCLI Directory.

If a school or ESA where you teach meets the requirements for inclusion
in the TCLI Directory for all or a part of a school year of your required 4
You are considered to be a full-time teacher if you meet the standard
school years of teaching, but does not meet those requirements in
used by the state where you teach in defining full-time employment as a subsequent school years, those subsequent years of teaching at that
teacher. If you are teaching in more than one school, the determination same school or ESA will still qualify for purposes of satisfying your TEACH
of full-time is based on the combination of all of your qualifying
Grant service obligation.
employment.
School year
Full-time

High-need fields

High-need fields are—
•
•
•
•
•
•
•

Bilingual education and English language acquisition;
Foreign language;
Mathematics;
Reading specialist;
Science (including, but not limited to, computer science);
Special education; or
Any other high-need field listed in the Teacher Shortage Area
Nationwide Listing (Nationwide List) at https://tsa.ed.gov/#/home/
that we issue annually and periodically update, including a

A school year is—
• One complete school year at the same school or for the same ESA;
or
• Two complete and consecutive half school years at different
schools or for different ESAs; or
• Two complete and consecutive half school years from different
school years at either the same school or for the same ESA or at
different schools or for different ESAs.
(definition of “school year” continues on page 5)

Page 4 of 7
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

SECTION 6: DEFINITIONS (CONTINUED)
School year (continued)
Half years do not include summer sessions. Two half school years
generally fall within a 12-month period. For schools or ESAs that have a
year-round program of instruction, a minimum of nine months is
considered to be a school year.
Under limited conditions, less than a full school year of teaching may still
be counted as one of your required 4 years. If you completed at least
one-half of a school year of qualifying teaching, but were unable to
teach for the remainder of the school year, that partial year may still be
counted toward one of your required 4 years of teaching if—
• Your employer considers you to have fulfilled your contract
requirements for the school year for the purposes of salary
increases, tenure, and retirement; and
• You were unable to complete the full school year due to (1) a
condition that is a qualifying reason for leave under the Family and
Medical Leave Act of 1993 (FMLA), (2) a call or order to Federal or
State active duty, or Active Service as a member of a Reserve
Component of the Armed Forces named in 10 U.S.C. 10101, 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); or (3) residing in or
being employed in a federally declared major disaster area as
defined in the Robert T. Stafford Disaster Relief and Emergency
Assistance Act (42 U.S.C. 5122(2).
Secondary school
A secondary school is a public or nonprofit private school, including a
public secondary charter school, that provides secondary education, as
determined under state law. However, a secondary school does not
include any education beyond grade 12.
Teacher
A teacher is a person who provides direct classroom teaching or
classroom-type teaching in a non-classroom setting, including special
education teachers and reading specialists.
TEACH Grant servicer
Your TEACH Grant servicer (identified in the General Information and
Instructions on page 1 and at the bottom of all other pages of this form)
monitors your progress toward completing your TEACH Grant service
obligation on behalf of the U.S. Department of Education.

Page 5 of 7
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

SECTION 7: IMPORTANT NOTICES
PRIVACY ACT NOTICE

its disclosure to federal, state, or local agencies, to private parties such
as relatives, present and former employers, business and personal
The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice
associates, to creditors, to financial and educational institutions, and to
be provided to you:
guaranty agencies to verify your identity, to determine your program
The authorities for collecting the requested information from and about eligibility and benefits, to permit making, servicing, assigning, collecting,
you are §420L et seq. and §451 et seq. of the Higher Education Act (HEA) adjusting or discharging your loan(s), to enforce the terms of the loan(s),
of 1965, as amended (20 U.S.C. 1070g et seq. and 20 U.S.C. 1087a et
to investigate possible fraud and to verify compliance with federal
seq.) and the authorities for collecting and using your social security
student financial aid program regulations, to locate you if you become
number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and
delinquent in your loan payments or if you default, or to verify whether
§31001(i)(1) of the Debt Collection Improvement Act of 1996 (31 U.S.C. your debt qualifies for discharge or cancellation. To provide default rate
7701(c)). Participating in the Teacher Education Assistance for College
calculations, disclosures may be made to guaranty agencies, to financial
and Higher Education (TEACH) Grant Program and/or the William D.
and educational institutions, or to federal, state or local agencies. To
Ford Federal Direct Loan (Direct Loan) Program and giving us your SSN
provide financial aid history information, disclosures may be made to
are voluntary, but you must provide the requested information,
educational institutions. To assist program administrators with tracking
including your SSN, to participate.
refunds and cancellations, disclosures may be made to guaranty
agencies, to financial and educational institutions, or to federal or state
The principal purposes for collecting the information on this form,
agencies.
including your SSN, are to verify your identity, to determine your
eligibility to receive a TEACH Grant, and, if a TEACH Grant that you
To provide a standardized method for educational institutions to
receive is converted to a Direct Unsubsidized Loan, to determine
efficiently submit student enrollment status, disclosures may be made
your eligibility to receive a benefit on the loan (such as deferment,
to guaranty agencies or to financial and educational institutions. To
forbearance, discharge, or forgiveness), to permit the servicing of
counsel you in repayment efforts, disclosures may be made to guaranty
your loan(s), and, if it becomes necessary, to locate you and to
agencies, to financial and educational institutions, or to federal, state, or
collect and report on your loan(s) if your loan(s) become delinquent
local agencies.
or in default. We also use your SSN as an account identifier and to
PAPERWORK REDUCTION NOTICE
permit you to access your account information electronically.
According to the Paperwork Reduction Act of 1995, no persons are
The information in your file may be disclosed, on a case-by-case basis or
required to respond to a collection of information unless it displays a
under a computer matching program, to third parties as authorized
currently valid OMB control number. The valid OMB control number for
under routine uses in the appropriate systems of records notices.
this information collection is 1845-0158. Public reporting burden for this
The routine uses of the information that we collect about you, if your
collection of information is estimated to average 20 minutes (0.33
TEACH Grant has not been converted to a Direct Unsubsidized Loan,
hours) per response, including time for reviewing instructions, searching
include, but are not limited to, its disclosure to federal, state, or local
existing data resources, gathering and maintaining the data needed, and
agencies, to institutions of higher education, and to third party servicers completing and reviewing the collection of information. The obligation
to determine your eligibility to receive a TEACH Grant, to investigate
to respond to this collection is required to obtain a benefit in
possible fraud, and to verify compliance with federal student financial
accordance with 34 CFR 686.40(a).
aid program regulations.
If you have comments or concerns regarding the status of your
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 our contractors for the purpose of
performing any programmatic function that requires disclosure of
records. Before making any such disclosure, we will require the
contractor to maintain Privacy Act safeguards. Disclosures may also be
made to qualified researchers under Privacy Act safeguards.

individual submission of this form, write to:
U.S. Department of Education
MOHELA
633 Spirit Drive
Chesterfield, MO 63005-1243

If your TEACH Grant has been converted to a Direct Unsubsidized Loan,
the routine uses of this information also include, but are not limited to,
Page 6 of 7
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600

Grant Recipient’s Name _______________________________________________________________ SSN ___ ___ ___ - ___ ___ - ___ ___ ___ ___
ADDITIONAL CHIEF ADMINISTRATIVE OFFICER’S CERTIFICATION
(TO BE USED IF A CERTIFICATION FROM MORE THAN ONE CHIEF ADMINISTRATIVE OFFICER IS REQUIRED)
SECTION 4: CHIEF ADMINISTRATIVE OFFICER’S (CAO’S) CERTIFICATION
Read the definitions in Section 6 before completing this section. Be sure to sign and date the form at the bottom of this page. Return the form to
the grant recipient.
1. What is the name of the school or educational service agency (ESA) where the grant recipient taught? Enter the name and other information
requested below, then continue to Question 2.
Note: If the grant recipient met the requirements for a full school year of teaching by teaching at different schools or for different ESAs and
you are authorized to certify the recipient’s teaching service at each school or ESA (for example, if the recipient taught at different schools
within the same school district), provide all information requested below for each school or ESA. Attach additional pages if necessary; include
all information requested in this section.
School (not school district) or ESA Name __________________________________________________________________________________
Check here if this is a school or ESA 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 ______________________
2. Was the grant recipient a full-time teacher who met all state certification requirements for teaching (which may include meeting the
requirements through certification obtained through alternate routes to teaching) during the school year(s) of teaching that you are being
asked to certify?
Yes – Continue to Question 3.
No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.
3. Were more than half of the classes that the grant recipient taught in the high-need field(s) indicated by the grant recipient in Section 2 (this
may include a geographic region or grade level with teacher shortages; see the definition of “high-need field” in Section 6)?
Yes – Continue to Question 4.
No – Do not complete this form. The teaching does not satisfy the terms and conditions of the TEACH Grant service obligation.
4. Has the grant recipient met their contractual requirements (for purposes of salary increases, tenure, and retirement) for a full school year of
teaching, and has that school year ended?
Yes – Continue to Question 5.
No – Do not complete this form. You can only certify teaching for a full school year of teaching that has ended.
5. Check the box below that describes how the grant recipient completed a full school year of teaching, then follow the instructions for the box
that you check. Check only one box.
The grant recipient completed a full school year of teaching during one school year at the same school or for the same ESA. Continue to
Question 6 and identify the school year.
The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years within the same
school year at different schools or for different ESAs. Continue to Question 6 and identify the school year.
The grant recipient completed a full school year of teaching by teaching for two complete and consecutive half years of teaching during
different school years at either the same school or for the same ESA or at different schools or for different ESAs. Skip to Question 7 and
identify the school year.
6. The grant recipient taught for the full 20___ ___ – 20___ ___ school year.
7. The grant recipient taught for the second half of the 20___ ___ – 20___ ___ school year and for first half of the 20___ ___ – 20___ ___ school
year.
I certify that the information I have provided above about the TEACH Grant recipient’s teaching service is true and correct.
CAO’s Name _____________________________________________________________________________________________________________
CAO’S Title (printed) ______________________________________________________________________________________________________
Telephone ( _______ ) _______ - _____________ Email _________________________________________________________________________

CAO’s Signature ____________________________________________________________________________ Date ___ ___ - ___ ___ - 20 ___ ___

Page 7 of 7
U.S. Department of Education * MOHELA * 633 Spirit Drive * Chesterfield, MO 63005-1243 * Fax: 1-866-222-7060 * mohela.com
TEL: 1-888-866-4352 *International: 636-532-0600