State of Wisconsin
Higher Educational Aids Board
P.O. Box 7885
Madison, WI 53707-7885
Scott Walker
Governor
Telephone: (608) 267-2206
Fax: (608) 267-2808
E-Mail: HEABmail@heab.wi.gov
John Reinemann
Executive Secretary
Web Page: http://heab.wi.gov
MINORITY TEACHER LOAN EMPLOYMENT VERIFICATION FORM
As a Minority Teacher Loan (MTL) recipient, you may be eligible for 25% loan forgiveness (see reverse side for
forgiveness criteria) for each academic year that you teach. You must complete sections A and B of this form,
and your school administrator must complete section C. Please submit your completed form to the Higher
Educational Aids Board (HEAB) at the end of your academic year. Illegible or incomplete forms will not be
accepted nor will forms submitted before the end of the academic year.
I am applying for 25% loan forgiveness for the
academic year.
Please indicate academic year (i.e. 2012-13)
Section A: MTL RECIPIENT INFORMATION (To be completed by MTL recipient)
Name
Social Security Number XXX-XX-
Mailing address
City
Phone
Degree earned:
State
Zip
Email
Bachelor
Master
Area of study:
Section B: MTL RECIPIENT EMPLOYMENT INFORMATION (To be completed by MTL recipient)
Name of school district
Name of school
School street address
Start employment date
City
Month:
Employment status
Year:
Full Time
End employment date
Part Time
State
Zip
Month:
Year:
If part time, list average hours per week:
DPI Educator File #
Section C: EMPLOYER VERIFICATION (To be completed by the school administrator)
I certify that the information provided in Section B is true and that this recipient of the Minority Teacher Loan
has been teaching as a licensed teacher at our school during the stated dates. I further certify that our school
qualifies under the statutes as either having at least a 29% minority student population or participating in the
inter-district pupil transfer program under State Statute 11.85.
Please print name:
Signature:
Mail completed forms to:
Higher Educational Aids Board
MTL Program
PO Box 7885
Madison WI 53707-7885
Title:
Date:
For more information, contact:
Deanna Schulz
Grant Specialist-MTL Program
Phone: 608-267-2212
Email: Deanna.schulz@wi.gov
MTL Recipient: You must complete and submit this form in order to have your loan forgiveness granted.
Updated: March 2013
MINORITY TEACHER LOAN
Terms of Loan Forgiveness
As a Minority Teacher Loan (MTL) recipient, you may be eligible for 25% forgiveness of your current loan
balance if, during the past academic year, you:
 Possessed a Bachelor’s or Master’s degree
 Held a valid Wisconsin Department of Public Instruction issued teacher’s license
 Were employed full time at an eligible school district (forgiveness is prorated for part time employment)
Eligible school districts are Wisconsin districts with a 29% or higher minority student population or Wisconsin
districts that participate in the inter-district public transfer program.
Eligible Wisconsin School Districts:
School districts with 29% or higher minority student populations:
Abbotsford
Greenfield
Milwaukee
Arcadia
Gresham
Nicolet UHS
Bayfield
Hayward
Norris
Beloit
Kenosha
Racine
Bowler
Lac du Flambeau
Saint Francis
Brown Deer
Lake Geneva J1
Sharon J11
Crandon
Linn J4
Sheboygan Area
Cudahy
Madison Metropolitan
Shorewood
Delavan-Darien
Maple Dale-Indian Hill
Siren
Glendale-River Hills
Menasha Joint
Sun Prairie Area
Green Bay
Menominee Indian
Tri-County Area
The following schools are located in Milwaukee County:
Bruce Guadalupe
King’s Academy
CEO Leadership Academy
Milwaukee College Prep-36th St
Capitol West Academy
Milwaukee Academy of Science
Central City Cyberschool
Milwaukee Math and Science Academy
DLH Academy
Milwaukee Scholars Charter School
Downtown Montessori
North Point Lighthouse Charter
Escuela Verde
School for Early Development & Achievement
School districts that participate in the inter-district pupil transfer program:
Elmbrook
Greendale
New Berlin
Fox Point J2
Hamilton
Nicolet
Franklin
Menomonee Falls
Oak Creek-Franklin
Germantown
Mequon-Thiensville
South Milwaukee
Verona
Walworth J1
Waukesha
Wausau
Wauwatosa
West Allis-West Milwaukee
Whitewater Unified
Wis Dept of Corrections
Wis Dept of Health Services
21st Century Prep School-Racine
Seeds of Health EI
Tenor High School
Urban Day School
Veritas High
Woodlands School
YMCA Young Leaders Academy
Whitefish Bay
Whitnall
Note: This list is subject to change annually.
Updated: March 2013