Request For Cancellation Benefit Or Deferment Prior To Cancellation

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: ___________________

Request For Cancellation Benefit Or Deferment Prior To Cancellation - State Of Illinois

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