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:
_________________________________ 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 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
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.