Fillable Request For Cancellation/deferment Form printable pdf download

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UNIVERSITY OF UTAH

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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:

__________________________________________________________________________________________________________________

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

Request For Cancellation/deferment Form

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