FEDERAL PERKINS (NDSL) STUDENT LOAN
REQUEST FOR CANCELLATION BENEFIT OR DEFERMENT PRIOR TO CANCELLATION
PART I -GENERAL INFORMATION TO BE COMPLETED BY BORROWER
Social Security Number:
Name:
Address:
City:
State:
Zip Code:
Cell Phone:
Email Address:
Home Phone:
Work Phone:
New Address : [ ] Yes
[ ] No
Name of Lending Institution: Midwestern University
I. Check box for type of full-time Service or Employment
Head Start
Early Intervention
Teaching - Handicapped/Special Education
Military
Nurse/Med. Tech
Teaching - Low Income
Bureau of Indian Affairs
Law Enforcement
Teaching - Math/Science/Bilingual Ed./Other Shortage
Peace Corps/VISTA
Child/Family Services
Name of SPECIFIC SCHOOL/Employing Agency/Hospital: __________________________________________
City: _________________________ State: __________________ Zip: ___________
II. Job Title: __________________________________________________________
THE FOLLOWING JOBS REQUIRE AN OFFICIAL JOB DESCRIPTION: Special Education Teachers, Teachers in Shortage Areas,
Early Intervention Services, Law Enforcement, Child/Family Services, Nurse and Medical Technicians. In addition to the Official Job
Description,
Nurse and Medical Technicians must provide: State Boards (date): _______/_______/_______ License #: ___________________
III. Declaration
I request deferment of payments of principal and interest while I complete the period of eligible service/employment required.
(The dates you list below may extend into the future.) I declare that I will notify my lending institution upon a change in my
status. 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 immediately. Employment/Service/Enlistment Dates (For teachers, dates must cover one academic
year or two consecutive semesters. For all others, dates must cover one complete calendar year. Please include copy of your contract
for the upcoming year. You must be employed full-time).
Begin _____/_____/_____ End _____/_____/_____
I hereby apply for a partial cancellation of my loan in the appropriate amounts of principal and interest for service or employment
as described above.(May be requested only after one full year completion of service/employment.)
Employment/Service/Enlistment Dates (For teachers, dates must cover one academic year or two consecutive semesters. For all
others, dates must cover one complete calendar year.)
Begin _____/_____/_____ End _____/_____/_____
Signature of Borrower (REQUIRED): ___________________________________ Date: ___________________