Paul Douglas Teacher Scholarship Program Performance Report

	PAUL DOUGLAS TEACHER SCHOLARSHIP PROGRAM
	PERFORMANCE REPORT FOR -
	Reporting Period:
	STATE:
	PLEASE READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM
	Section I: Summary Repayment Information				Section II: Fulfillment of Scholarship Obligation
		Number of Recipients as of:				Number of Recipients as of XXXXXX who have
	1.	In repayment status			A. Completed the teacher
	2.	In default status				certification course of study:
	3.	In deferment status			B. Taught by grade level:		Public-A		Private-B
	4.	Total - Cumulative	0		1.	Preschool level
					2.	Elementary level
	B. Not in repayment status & not teaching:				3.	Secondary level
	1.	Still pursuing course of study			4.	Total - Cumulative	0		0
		leading to teacher certification
	2.	No longer pursuing teacher			C. Taught in teacher shortage area:
		certification course of study			1.	Geographic
	3.	Certified to teach but not yet			2.	Grade level
		teaching (grace period)			3.	Subject matter
	4.	Total - Cumulative	0		4.	Total - Cumulative	0
	C. Amount repaid during FY:				D. Complete the Scholarship obligation:
	1.	Principal			1.	By teaching
	2.	Interest			2.	By repaying the Scholarship
	3.	Total	$0		3.	By teaching & repayment
					4.	Total - Cumulative	0
	D.	Amount of principal as of XXXXX:
	1.	Total outstanding			E. Had the Scholarship obligation
	2.	In default status				cancelled:
	3.	In deferment status
					Section III: Summary Outcomes for all Former Scholars
	E.	Amount of uncollectible debt written			A.	Not in repayment status and not teaching	0
		off as of XXXXXX:			B. Teaching
	1.	Principal written-off			C.	In repayment status	0
	2.	Interest written-off			D.	Completed or cancelled obligation	0
	3.	Total - Cumulative	$0		E.	Written-Off	0
	4.	Number of Scholarships written-off			F.	Total - Cumulative	0
	Section IV: Certification by Authorized Official
	I certify that the information provided in this Performance Report is based upon information reflected in the official accounting and program records of this agency. Upon request, such records will be made available to the Secretary or his delegate for review.
	SIGNATURE					DATE
	TYPED NAME/TITLE OF AUTHORIZED OFFICIAL
	TELEPHONE NUMBER (AREA CODE) AND EXTENSION
	FAX NUMBER (AREA CODE)					E-MAIL ADDRESS
	NAME OF STATE AGENCY
						ED Form Number(s): XX-XXX, XX.XXX
	STREET ADDRESS
						OMB NUMBER: 1840-0787
	STREET ADDRESS
						Expiration Date: XX/XX/XXXX
	CITY/STATE/ZIP CODE
	According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1840-0787. Public reporting burden for this collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 12 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit under Title V Part C, Subpart 1 of the Higher Education Act of 1965, as amended (20 U.S.C. 1104 through 1104K). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Avenue., S.W. Washington, DC 20202-4536 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1840-0787. Note please do not return the completed Paul Douglas Teacher Scholarship Program Performance Report to this address.