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UNIVERSITY OF UTAH
Print Form
FEDERAL PERKINS & NDSL Request for Cancellation/Deferment
Part I – To be completed by the Borrower (Complete in INK)
Name:
Account Number:
Street Address:
City:
State:
ZIP:
Home Phone:
Work Phone:
I am requesting a
Deferment for
Beginning (mm/dd/yy)
Ending (mm/dd/yy)
Cancellation………………..
Cancellation………………………
Beginning (mm/dd/yy
Ending (mm/dd/yy)
(Please check all that apply)
(Please refer to your promissory note for specific eligibility requirements)
Indicate type of full time service:
Teacher: School District/County___________________
Nurse/Medical Technician
Peace Corps, ACTION volunteer
School_______________________ Grade____________
Position
Military Combat for at least one
Low Income School
_____________________________
year in an area of hostility
Pre-School Head Start
Provider of Services to High-Risk
Specify area
Teacher Math, Science, Foreign Language, Bilingual Ed
children from low income
__________________________
Subject _______________________________________
communities at a non-profit
Teach Handicap/Special Education type _____________
Child/Family Service Agency
Percentage of handicapped/Special Ed children________
Full-time Law Enforcement Officer
Position ______________________
Early Intervention Services
Infants and Toddlers to Age 2
I understand that by requesting a deferment or cancellation during my original grace period, I am conditionally waiving my rights to said grace period.
THIS FORM IS INVALID WITHOUT: BORROWER’S SIGNATURE, ACCOUNT NUMBER, BEGINNING AND ENDING DATES, AND
COMPLETE CERTIFICATION. I HEREBY CLAIM THAT THE ABOVE INFORMATION IS TRUE. I AGREE TO NOTIFY INCOME
ACCOUNTING AND STUDENT LOAN SERVICES IMMEDIATELY IF MY STATUS CHANGES.
Borrower’s Signature__________________________________________________
Date___________________________
PART II – TO BE COMPLETED BY CERTIFYING OFFICIAL
I certify that the information stated above and below is correct:
X
__________________________________________________________________________________________________________________
Signature of Authorizing Official
Title
Date
Name and Address of Organization
JOB TITLE
__________________________________________
__________________________________________
___________________________
__________________________________________
Official Stamp or Seal (if
Phone Number (
)_______________________
available)
Dates of completed employment
Dates of anticipated future employment
From______________________
From________________________
To________________________
To__________________________
Full time
Part time # hrs
Full time
Part time # hrs
RETURN FORM TO: University of Utah, Income Accounting & Student Loan Services, 201 South 1460 East Room 165, Salt Lake City, Utah 84112
Phone: 801 581-8786
Toll free: 1-800-444-8638 ext: 1-8786
Fax: 801 581-4277