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
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