Fillable Printable Request for Cancellation Form

Request for Cancellation Form

We recommend that you read your promissory note carefully in order to become familiar with a number of features, duties, and,

more specifically, what is and is not available relating to a deferment or cancellation before completing this form.

BORROWER'S NAME/ADDRESS: MAIL FORM TO:

______________________________

ECSI

_________________________________ 181 Montour Run Road

Coraopolis, PA 15108-9408

_________________________________

EMAIL ADDRESS: ACCOUNT NUMBER:

LENDING INSTITUTION: (Last 4 digits of SSN OR SID)

Section 1 Perkins Cancellation Type

Refer to the specific section on the backside of this form

This is to certify that I am employed FULL TIME as a:

____ Teacher in a designated school listed in the ‘Federal Register’ (Section A)

____ Special Education Teacher or qualified provider of Early Intervention Services / Teacher of Handicapped (Sections A.B)

____ Teacher of Mathematics, Science, Foreign Languag es, Bilingual Education (loans after 7-23-92) (Section A)

____ Staff member performing qualified service und er the Headstart Act (Section C)

____ Nurse – must provide copies of License/Certification (Section D)

____ Medical Technician – must provide copies of License/Certification (Section D)

____ Law Enforcement/Corrections Officer for an eligible Local, State, or Federal Agency (after 11-29-90) (Section E)

____ Service agent providing or superv ising the provision of services to High Risk Children for Low-Income

Communities and Families of such children (after 7-23-92) (Section F)

____ Military Service Cancellation (Section G)

____ Peace Corps volunteer or Americorps*VISTA volunteer

(Section H)

Section 2 Certification Period

Please complete all of the following that applies:

Deferment in anticipation of cancellation (for THIS or NEXT year) – Starting date_____________ End ing date______________

Cancellation for year of work completed (for PREVIOU S year) - Starting date_____________ Ending date______________

If for any reason I am unable to complete the YEAR of service, I will inform ECSI of the change in full time status immediately.

Section 3 Borrower Signature

I declare that the information above is true and correct.

Signature of borrower____________________________ Da te______________ Day Phon e_____________ Even ing Phone______________

Section 4 Certification by Employer

I certify that the information stated above is true and correct.

Employed by schoo l, hospital, dept., or agency ____________________________________ Coun ty_________________________

Start date of employment: (mmddyy)_________ Is empl oyee still employed ? Yes___ No___ End date of employment_________

School name________________________________________________ Address_________________________________________

City_____________________________________________________ State__________ Zip____________ Phone_______________

Description of Exact Duties__________________ _________________________________ Please attach an off icial Job Description

Signature of Authorized Official_____________________________________________________ Date_______________________

Printed name of Authorized Official __________________________________________________Title_______________________

THIS FORM IS INVALID WITHOUT OFFICIAL INSTIT UTIONAL SEAL, STAMP PLACED HERE:

(NOTARY SEAL NOT ACCEPTABLE)

IF EMPLOYER SEAL OR STAMP NOT AVAILABLE PLEASE ATTACH LETTERHEAD CERTIFICATION:

A letter written on employer letterhead by the employer verifying full time dates of employment and job de sc r i ption

THIS FORM WILL BE RETURNED TO BORROWER IF INCOMPLETE

A. Teacher Cancellation: A teacher in a school serving students from low-income families; A special-education teacher, including

teachers of infants, toddlers, children, or youth with disab ilities; or a teacher in the fields of mathematics, science, foreign

languages, or bilingual education, or in an y other field of experti se that is determined by a state education agency to have a shortage

of qualified teachers in that state.

B. Early Intervention Cancellation: Schools must cancel up to 100% of a Perkins Loan if the borrower has been employed full time as

a qualified professional provider of early intervention services in a public or other nonprofit program under public supervision.

C. Head Start Cancellation

Schools must cancel up to 100% of a Perkins Loan if the borrower has served full time as a staff member in th e educational part of a

preschool program carried out under the Head Start Act.

A full-time staff member is someone who is regularly employed in a full-time professional capacity to carry out the education a l part of

a Head S tart Pr ogram.

D. Nurse or Medical Technician Cancellation

Schools must cancel up to 100% of a Perkins Loan if the borrower has served full time as a nurse or medical technician providing

health care services. The borrower must provide health care services directly to patients.

E. Law Enforcement or Corrections Officer Cancellation

Schools must cancel up to 100% of a Perkins Loan if the borrower has served full time as a qualifying law enforcement or corrections

officer. To establish the eligibility of a borrower for the law enforcement or corrections officer cancellation provision, the school must

determine that (1) the borrower’s employing agen cy is eligible and that (2) the borrower’s position is essential to the agency’s primary

mission.

F. Child or Family Services Cancellation

Schools must cancel up to 100% of a Perkins Loan if the borrower has served full time as an employee of an eligible public or private

nonprofit child or family service agency and has provided or supervised the provision of services to both high-risk children who are

from low-income communities and the families of such children. To receive loan cancellation for being employed at a child or family

services agency, a borrower must be providing services only to high-risk children who are from low-income communities. The

borrower may also be providing services to adults, but these adults must be members of the families of the children for whom services

are provided. The services provided to adults must be secondary to the services provided to the high-risk children. The Department has

determined that an elementary or secondary school system or a hospital is not an eligible employing agency.

G. Military Service Cancellation

Schools must cancel up to 50% of a Perkins Loan if the borrower has served a period of full-time active duty in the armed forces (that

is, the U.S. Army, Navy, Air For ce, Ma rine Cor ps, o r Coas t Gua rd), the National Guard, or the Reserves. The service must be in an

area of hostilities or an area of imminent danger that qualifies for special pay under Section 310 of Title 37 of the U.S. Code. The

cancellation rate for every complete year of qu a lifying service is 12.5% of the origin al

principal loan amount.

H. Volunteer Service Cancellation

Schools must cancel up to 70% of a Perkins Loan if the borrower has served as a Peace Corps or Am ericorps*VISTA (under Title I,

Part A of the Domestic Volunt eer Service Act of 1973) volunteer. An authorized official of the Peace Corps or Americorps*VISTA

program must sign the borrower’s cancellation form to certify the borrower’s service. Americorps volunteers do not qualify for this

cancellation unless their volunteer service is with Americorps*VISTA. An Americorps*VISTA volunteer may onl y qualify for this

cancellation if the Americorps*VISTA volunteer elects not to receive a national service education award for his or her

volunteer service. The Americorps*VISTA volunteer must provide appropriate documentation showing that the volunteer has

declined the Americorps national service education award.