Teacher Prep Stipend Application Form

TEACHER PREP STIPEND APPLICATION FORM

Use this form to request reimbursement or direct payment of a Teacher Preparation Stipend for coursework, workshops, or supervised clinical experiences that directly support teacher certification or licensure. Submit complete documentation with this application. Incomplete or false information may result in denial, repayment obligation, and administrative action.

Applicant Information

Date of Birth:    Student/Employee ID:

Pre-service or undergraduate teacher candidate    In-service teacher (employed)    Other:

Program / Course Details

Course Start Date:    Course End Date:    Total Contact Hours:

Eligibility Affirmations

By checking each box below, I affirm the corresponding statement is true and understand that falsification may require repayment and disciplinary action.

I am currently enrolled in, or formally accepted to, the program or course listed above and agree to provide proof of enrollment or registration.

I am not receiving duplicate stipend or grant funding for the same course or activity from this agency or another institutional source.

If a GPA requirement applies, I meet the minimum academic standard required by the funding program and will submit transcripts if requested.

I commit to completing the course/workshop and to submitting completion documentation (grade, certificate, or attendance verification). If I do not complete the activity, I understand I may be required to repay all or part of the stipend.

Required Attachments (Attach all that apply)

Transcript or most recent academic record:

Enrollment verification or registration confirmation:

Course syllabus or agenda:

Invoice or cost estimate (if requesting reimbursement for tuition/fees):

Certification and Agreement

I certify under penalty of law that the information in this application and any attachments is true, correct, and complete to the best of my knowledge. I authorize the program administrator to verify enrollment, attendance, grades, or completion records as necessary to determine eligibility and to process payment.

I understand that stipend funds are awarded for the sole purpose described in this application. If I fail to complete the activity or if the funds are used for ineligible purposes, I agree to repay the stipend upon demand. The program reserves the right to withhold current or future payments, recoup funds, or seek other remedies for misrepresentation or noncompliance.

I acknowledge that any stipend paid may be reportable as taxable income and that I am responsible for any tax liability. I further understand that the program may require submission of tax documentation prior to payment and that payment is subject to available funding and administrative approval.

Program Coordinator / Administrative Use

Approval Status: Approved    Denied

Sign Now