Full Name *

Date of birth *

Phone *

Email *

Gender *

Male

Female

Address *

Your School District? *

Your School Building? *

What Subject do you Teach? *

Consecutive Years as Teacher? *

Your Annual Adjusted Income? *

Number of Dependant Children? *

Any Banruptcies in Past 7 Years? *

Yes

No

How do you File Taxes? *

Single

Married - Separately

Married - Jointly

Head of HouseHold

ADDITIONAL INFORMATION?

Is your Loan in Default? *

Yes

No

Received Forgiveness Before? *

Yes

No

Types of Loan? (Check all that Apply) *

Parent Plus

Perkins

FFEL

Direct

Private

Federal

Current Repayment Plan *

10 Year Level

20 Year Level

30 Year Level

Graduated

Income-Based

Unknown

Plan to Stay in Current Position in Next 10 Years? *

Yes

No

Planning to Take Additional Loans? *

Yes

No

Amount of Fed Loan? *

Fed Loan Monthly Payment? *

Private Loan Monthly Payment?

Spouse Loan Amount?

Loan Interest Rate?

Additional Information or Comment?

Currently Contriute to 403b, 401k, 457? *

Yes

No

Does your Employer Match? *

Yes

No

Current Contribution Amount? *

Your Estimated Retirement Year? *

Interested in Any of the Following *

Donors Choose

State Teacher Retirement

Financial Success

Educators Auto-Home Ins

Life Insurance

Cancer - Disability Ins

Other

None of the Above