Georgia Form H 13 – Fill Out and Use This PDF

Statement of Intentions

HOPE Teacher Scholarship Loan Program • PROMISE Teacher Scholarship Loan Program

PROMISE II Teacher Scholarship Loan Program

Please review Section A, complete Section B as directed, and return within 30 days.

SECTION A

You may request consideration for service cancelation eligibility when:

1.You are employed for a year at an approved site in Georgia, and

2.You have satisfi ed State of Georgia certifi cation requirements in the subject area for which the Georgia Student Finance Authority (GSFA) awarded the HOPE Teacher Scholarship Loan or the PROMISE Teacher Scholarship Loan, and

3.You have provided a copy of your Georgia Educator Certifi cate refl ecting the level and degree attained. NOTE: Provisional certifi - cates (B) and Probationary certifi cates (PA) are not acceptable for service cancelation credit.

Upon receipt by GSFA of your Statement of Intentions (as indicated in Section B below), you will be notifi ed in writing whether your employment site qualifi es for service cancelation.

Each year GSFA will send you a Notifi cation of Satus form requesting updated information on your employment status. The form must be completed and returned by the date indicated, or your service cancelation option will be forfeited.

SECTION B

PRINT: Last Name: _____________________ First Name: ____________________ M.I. _____ Maiden Name: ________________

Social Security Number: _______________________ Telephone Numbers: Work: ( ____ ) ____________ Home: ( ____ ) ____________

Permanent Mailing Address: _____________________________________________________________________________________

City: ___________________________________________ State: ________ ZIP: _________________

INSTRUCTIONS: Please indicate your intentions by checking ONE of the following four options and complete the recipient’s verifi cation information below. In addition, if you are applying for service cancelation, please complete the Teacher Education Site of Employment information below and attach a copy of your Georgia Educator Certifi cate.

I wish to exercise my one year grace period before applying for service cancelation of my scholarship loan. I understand that my grace period begins on the date of my graduation. I graduated on (Month/Year): ______________.

I have not graduated from the program of study for which the scholarship loan was awarded. I understand that I must complete my approved degree program of study with 5 years beginning with the fi rst term for which scholarship loan funds were awarded and that I cannot have a break-in-enrollment of more than 12 months. My new anticipated graduation date is (Month/Year): ______________.

I wish to repay my scholarship/loan in cash. (NOTE: Accounts converted from scholarship to loan status will be forwarded automati- cally to our servicing department. All terms and conditions of your Promissory Note remain in effect.) You will be notifi ed in writing of your repayment schedule.

I wish to apply for service cancelation of my HOPE Teacher Scholarship Loan or PROMISE Teacher Scholarship Loan. Attached is a copy of my Georgia Educator Certifi cate, which refl ects the level and fi eld for which the scholarship loan was awarded. (Complete Site of Employment and Recipient’s Verifi cation information below and deliver to your employer for certifi cation.)

Signature: ________________________________________________ Date: ____________________________

Teacher Education Site of Employment

This is to certify my current employment in the teaching/service position below for service cancelation of my GSFA obligation.

I graduated from (name of college or university): _______________________________________ on (Month/Year): _______________

I am employed for an academic year, beginning (date)	From: ___________________	To: ___________________
I am employed for a Summer Term, beginning (date)	From: ___________________	To: ___________________

Employing School System/Institution: _____________________________________________________________________________

School Name: ________________________________________________________________________________________________

School Address: ____________________________________________ City: ___________________ State: _____ ZIP: __________

Recipient’s Verification: I hereby certify that the above information is true and acknowledge my responsibility to notify GSFA promptly of any change in my permanent mailing address or employment status.

Signature: ________________________________________________ Date: ____________________________

Employer’s Verification: I hereby certify that the individual above is employed in the school system/institution and in the following fi eld.

Teaching/Service Field: ____________________________ Grade Level: ____________ Subject Area: _________________________

Signature (Superintendent/Superintendent’s Designee): ____________________________________________ Date: ______________

Name (Print): ___________________________ Title: ____________________________________ Telephone: ( ____ ) ____________