Federal Perkins (Ndsl) Student Loan - Request For Deferment Page 2
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2SECTIONS A-E MUST BE COMPLETED FULLY
This space for servicer’s use only
BORROWER MUST COMPLETE ALL AREAS OUTLINED IN RED AND/OR IN DASHES
This space for servicer’s use only
Federal Perkins (NDSL) Student Loan – Request for Cancellation
Please print-This section must be filled out completely.
Name
Social Security No.
Account number(s) on billing statement
Address
Check if new address
City
State
Zip
Home Phone
Work Phone
(
)
(
)
Return to: Campus Partners
Email Address
Cell Phone
P.O. Box 2901
(
)
Winston-Salem, NC 27102-2901
Fax: 336-607-2093
Institution that granted this loan(s)
You may qualify for partial loan cancellation benefits, regardless of the terms or your promissory note. There are a number of reasons that may qualify you for these
benefits. For a complete list of cancellation provisions and the eligibility criteria for each one, please visit our web site at
or you may contact our
office at (800) 334-8609.
*****Two forms are required for each year, a Request for Deferment submitted at the beginning of the year and a Request for Cancellation at the end of that year’s service.*****
A. Cancellation or Deferment
E. Certification of Employment or Enlistment Period
*Additional documentation required. Please visit our Web
CHECK BLOCK(S) FOR TYPE OF SERVICE
site at
and complete the Official
Certification Letter For Cancellation Benefits.
Name of School, Place of Employment or Service Unit
Child Care Program*
Middle School
Law Enforcement*
Early Intervention*
Headstart*
High School
Public Defender
Peace Corps/VISTA
Address
Phone No.
Pre-Kindergarten*
Speech/Language
Nurse/Medical
Military (Combat)
Pathologist*
Technician*
County
School District
Kindergarten
Librarian*
Firefighter
Elementary
Tribal Faculty
Child/Family Service*
College/University
City
State
Zip
Spec. Ed
Attach a description of your students or clients and the percentage of disabled in the
.:
Please check all
classroom.
boxes that apply.
I CERTIFY THAT THE BORROWER IS EMPLOYED FULL TIME.
Legal Name of School or Employing/Educational Agency
I certify that this is a public elementary or secondary school.
I certify that this school is operated by the Bureau of Indian Affairs.
I certify Peace Corps/VISTA.
City
State
Zip
I certify that this is a private or public nonprofit elementary or secondary school registered by the
B. Employment or Enlistment Period (must be one complete year)
STATE EDUCATION AGENCY (verification should be attached by certifying official).
Beginning
and
Ending
I certify that this is a public or private nonprofit child or family service agency.
Deferment in
Anticipation of
Mo.
Day
Yr.
Mo.
Day
Yr.
Cancellation
Signature of Certifying Official
Date
Beginning
and
Ending
Cancellation
Mo.
Day
Yr.
Mo.
Day
Yr.
Title of Certifying Official
C. Job Title/Description/Subjects
*Note: Altered dates must be initialed by Certifying Official
This space for Institutional Seal. If not available, provide official letter of certification.
State Board Date(s)
Med Tech/RN Lic. Date(s)
SEAL
Original
Must complete for
Received/
nurse/med
tech.
Pass Date
Mo.
Day
Yr.
Mo.
Day
Yr.
D. Declaration
I declare that the information shown above is true and accurate. I further declare that
For lending institution only:
I will notify my lender immediately upon change in my status. I further understand
Cancellation approved
Deferment approved Principal Cancelled $
that if, for any reason, I am unable to complete the year of service for which I have
requested deferment benefits, I will begin repayment of my loan immediately
.
Defense (10%, 15%)
Request disapproved Interest Cancelled $
Perkins (15%, 20%, 30%)
Signature of
Borrower (required)
Date
Signature
Date
Internal use only: Date
Analyst’s Initials
t
Commen
Last 3 digits
Begin
End
Program No.
SEQ No.
Type
Mo.
Year
Mo.
Year
QL
Principal cancelled
Interest cancelled
QL
Principal cancelled
Interest cancelled
QL
Principal cancelled
Interest cancelled
QL
Principal cancelled
Interest cancelled
9164F (11-09)
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