Fillable Printable Request for Cancellation - Federal Perkins Loan
Fillable Printable Request for Cancellation - Federal Perkins Loan
Request for Cancellation - Federal Perkins Loan
REQUEST FOR CANCELLATION - FEDERAL PERKINS LOAN
(Please complete in ink)
Name Lending Institution 16 Digit Account Number
Address
Home phone: ( )
Work Phone: ( )
Cell Phone: ( )
Dates Requested (mm/dd/yy):
Begin Date: ______________
End Date: ________________
Email:
Driver’s License #/State: Birthdate:
Return Form to:
ACS Education Services
Campus Products and Services
P.O. Box 7060
Utica, NY 13504-7060
You may qualify for one of the following partial loan cancellation benefits, even if they are not specifically listed in your
original promissory note. Please visit our website for further information or clarification:
www.acs-education.com
Full-time Teacher of:
Elementary/Secondary low-income school determined by
the Federal Government
Special Education for Infants/Toddlers/Youth with
Disabilities – classroom must be 100% Special Education
Indicate of type of specialty________________________
Mathematics, Science, Foreign Language, Bilingual
Education or state designated shortage area
Subject taught: __________________________________
Head Start
Service Cancellation available after 8/14/08:
Pre-K staff member service
Tribal College/University Faculty
Name of School or Employing Agency:
____________________________________________________
County/ School District
____________________________________________________
City State Zip
Other Service Cancellations (must serve full-time):
Criminal Law Enforcement/Corrections Officer
Nurse/Medical Technician
Child/Family Services to high-risk children from low-
income communities
Early Intervention Services (under the age of 3)
Peace Corps/Volunteer Services
Military Service (Combat for at least one year in an area
of hostility/imminent danger)
Surviving spouse of eligible public servant - 9/11 attacks
Service Cancellations available after 8/14/08:
Firefighter (Full-time employment)
Attorney employed in a defender organization
Librarian serving Title I school
Master’s degree in Library Science required
Speech Pathologist in Title I school
Master’s degree in Speech Pathology required
Please include a statement on employer letterhead with full
job description/job duties and copy of job license.
DEFERMENT FOR PRE-CANCELLATION SERVICES
I expect to be eligible for a cancellation for the period ________ to ________ and request a deferment until I have completed
a full year of service (in the category specified above) at which time I will provide the proper documentation.
I declare that the information shown above is true and accurate. I further declare that I will notify my lender immediately upon
any change in my status. If I am unable to complete the year of service for which I have applied for cancellation or deferment,
I will begin loan repayment immediately.
Borrower Signature: ________________________________________________________ Date: ________________________
Official Stamp or Seal
(If no stamp or seal is available,
please provide supporting
documentation on official
letterhead)
CERTIFICATION OF EMPLOYMENT/ENLISTMENT
Name of Employer: ___________________________________________
Address: ___________________________________________________
___________________________________________________
___________________________________________________
Phone: ( )_________________________________________________
I certify that the information stated above is correct.
Employment Status : ____ Full Time
____ Less than Full-Time – number of hours per week________
Employed From:____________ To:_____________
Signature of Certifying Official: ________________________________________
Title of Certifying Official: ____________________________________________
Date: _______________________
INTERNAL USE ONLY:
Cancellation Approved/Processed
Deferment Approved/Processed
Date Processed: ______________
Processor: _________________
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