Request For Cancellation Benefit Or Deferment Prior To Cancellation Form printable pdf download

FEDERAL PERKINS (NDSL) STUDENT LOAN

REQUEST FOR CANCELLATION BENEFIT OR DEFERMENT PRIOR TO CANCELLATION

For questions, please visit our website or call 800-999-6227.

Name:

Account Numbers:

Address:

Email Address:

City:

Social Security Number:

State:

Zip Code:

Employment Telephone: (

)

 Check here if this is a new address.

Home Telephone: (

)

College or University where loan originated:

Cell Telephone: (

)

I. Check box for type of full-time Service or Employment

 Head Start/Pre-kindergarten/Childcare

 Early Intervention

 Teaching – Special Education

 Military

 Nurse/Med. Tech

 Teaching – Low Income

 Bureau of Indian Affairs/Tribal Faculty

 Law Enforcement/Public Defender

 Teaching – Math/Science/Bilingual Ed./Other Shortage  Peace Corps/VISTA

 Child/Family Services

 Firefighter

 Librarian

 Speech Language Pathologist

Name of SPECIFIC SCHOOL/Employing Agency/Hospital:

City:

State:

Zip

County:

School District:

II. Job Title:

If teaching; provide grade level(s):

(Grade levels K-12)

Subject:

THE FOLLOWING JOBS REQUIRE AN OFFICIAL JOB DESCRIPTION: Special Education Teachers, Teachers in Shortage Areas, Head

Start/Pre-kindergarten/Childcare, Early Intervention Services, Law Enforcement, Child/Family Services, Medical Technicians.

Nurse, Medical Technicians and Speech Pathologists must provide: State Boards:

License #

(Date Passed)

III. Declaration (Forms must be filed annually ):

I request deferment of payments (Current or next employment year) Employment/Service/Enlistment Dates: Dates must cover one

complete calendar year. For teachers, dates must cover two consecutive semesters.

Begin

End

I hereby apply for a partial cancellation. I understand that I may only request this benefit after a full year (or academic year) of employment.

Begin

End

REQUIRED** Signature of Borrower

Date:

I understand that if, for any reason, I do not complete the year of service for which I have requested deferment benefits, I will begin repayment of my loan following my 6-month grace period.

FORMS NOT SIGNED BY THE BORROWER WILL BE RETURNED.

IV. Certification of Employment, Service, or Enlistment Period:

This space is provided for the organization’s official seal or

Date of Hire: ___________________ Currently Employed:  Yes  No

stamp.

**If one is not available, provide a letter of

certification confirming the borrower’s service, employment,

If NO, please indicate Last Day of Employment:

________

or enlistment on official letterhead and include employee’s

Address:

start date and full-time status.

City:

State:

Zip:

Telephone Number: (

)

If borrower is a shortage teacher, please specify subject:

I certify borrower is employed full-time. I further certify that the information provided

by the borrower regarding his/her service/employment is true and correct.

Signature of Official:

Title:

Date:

For Internal Use Only

 Listed in Federal Register

Year Listed

 Not Listed in Federal Register

Cancelled at

Code:

End Date:

Letter Sent:

Fund

Principal

Interest

Balance

Fund

Principal

Interest

Balance

1029

103C

Fund

Principal

Interest

Balance

103A

103D

Fund

Principal

Interest

Balance

103B

103E

Deferred From:

To:

# Mos:

Grace Ending Date:

Processed by:

Date:

Lending Institution Only:

(Signature of Approving Official)

(Date)

TSE/CD 001

08/10

Request For Cancellation Benefit Or Deferment Prior To Cancellation Form

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