Loan Office
Page 1
351 West Center
Cedar Cit y, UT 84720
(435) 586-7728
htt p://ww w.suu.edu/ss/loans/index.htm l
Nam e So c i al Se c u r i t y N u m b e r
T number
Address Ci t y State ZIP
______________________________________________________________________________________________________
Daytime Phone Number
Cell Number Email:
Please complete and return this form to the address listed above. Final responsibility for return of this form in a timely manner
rests with the borrower. Late requests for deferment/cancellation are subject to late fees. No deferment/cancellation is
possible until this form is returned to SUU Loan Office. Part 1 is to be completed by the borrower; Part 2 must be certified by
the employer. This form is invalid without borrower's signature, correct dates, and official verification and certification.
PART 1
: I r eq u est p ar t i al can ce llat io n o f m y Fed er al Pe r ki n s Lo an : My Full y ear o f such em p lo ym en t b eg an ___________an d en d ed ________
DATES Month/Day/Year
_____Employed full-time as an elementary or secondary school teacher at a qualified school.
(
School must be listed in the Federal Register from the Department of Education.)
Fr o m To
_____Employed full-time as a special education teacher in an elementary
or secondary school. Fr o m To
_____Employed full-time as a teacher of math, science, foreign language, or
other designated shortage area. Fr o m To
_____Employed full-time as a professional provider of early intervention.
It must be a public or other nonprofit program under public supervision by a agency as
Fr o m To
authorized by section 632(5) of the Individuals lead with Disabilities Education Act.
Early intervention services are provided to infants and toddlers with disabilities.
_____Employed full-time as a law enforcement/corrections officer.
Fr o m
To
_____Employed full-time as a state licensed Registered Nurse or Medical Technician.
Fr o m To
_____Em p lo y e d f u ll-t im e b y a c h ild o r f am ily ser v i ce ag en cy :
They m ust be a eligible public or private non-profit child or family service Fr o m To
who is directly providing or supervising the provisions of services to
high-risk children who are from low-income communities and the
families of such children.
_____ Employed full-time Attorneys Employed in a Defender Organization
__________________________________________________
Fr o m TO
Federal Perkins/Nat ional Direct St udent Loan Request for Part ial Cancellat ion
and Certification of Employer
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_____Employed full-time as a Firefighters
Working for a Local, State or Federal fire department or fire district. __________________________________________________
Fr o m To
______Employed full-time as a Tribal College or Universit y Faculty : __________________________________________________
Fr o m To
______ Em p lo y e d f u ll-t im e as a Lib r ar ian __________________________________________________
Librarian who has a m asters degree in library science and is employed Fr o m To
in an elementary or secondary school that is eligible for assistance
under part A of title I of the Elementary and Secondary Education Act
of 1965, or who is employed in a public library that serves a geographic
area that contains one or more such schools.
______Em p lo y e d f u ll-t im e as a Sp e ech -Lan g u ag e Pat h o lo gist __________________________________________________
Speech-language pathologist who has a master’s degree and who is Fr o m TO
working exclusively with schools that are eligible for assistance under
title I of the Elementary and Secondary Education Act of 1965.
_____Employed full-time as Service in an Early Childhood Education Program
Be a member in the educational component of a Head Start program, or
Fr o m To
full-time staff member in a pre-kindergarten or child care program that is
licensed or regulated by the State. The program must be operated for
a period com parable t o a f ull School year and m ust pay a salary
comparable to an employee of a local educational agency.
_____Military Cancellation: You can be entitled to have up to 50 percent of the
principal amount of your loan canceled for qualifying service that ended
Fr o m To
before Aug 14,2008 and up to 100 percent cancelled f or qualif ying
service that began on or after Aug 14,2008;as a member of the
Armed Forces of the United States in a area of hostilities that qualifies
for special pay under section 310 of Title 37 of the United States Code.
_____Vo lu n t eer Se r vice Can cellat io n :
You are entitled to have up to 70 percent of the original principal loan Fr o m To
canceled for qualifying service performed after the enrollment period
covered by the loan as a volunteer under the Peace Corps Act. Or
a volunteer under the Domestic Volunteer Service Act of 1973.
I agree to notify the SUU Loan Office immediately upon termination of my present status and request another deferment in writing whe
I understand and agree that a deferment can be granted only if I qualify according to Federal guidelines applicable to my loan fund(s) and
abide by the terms and conditions outlined in my promissory note.
______I w i ll a lso b e e m p lo y ed n e x t y e ar .
Signature of Borrower Dat e
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Part 2: Certification of Employer
I certify the information in stated in Part 1 is true and correct.
_____Employed full-time as an elementary or secondary school teacher at a qualified school.
_____Employed full-time as a special education teacher in an elementary or secondary school.
_____Employed full-time as a teacher of math/science/language or the designated shortage area.
_____Employed full-time working as with Early Intervention Services.
_____Employed full-time as a law enforcement/corrections officer.
_____Employed full-time as a state licensed Registered Nurse or Medical Technician.
_____Employed full-time by a child or family service agency serving low income communities as defined by th
Department of Education.
_____Employed full-time as a Attorney employed in a Defender Organization.
_____Em p lo y ed f u ll-t im e as a Fir ef ig h t er
_____Employed full-tim e at a Tribal College or University Faculty
_____Em ployed f ull-tim e as a Librarian w ho has a m ast er's degree in Library Science
_____Employed full-time as a Speech -Language pathologist with a master's degree
_____Employed full-time with Service in and Early Childhood Education Program. Head Start
_____Volunteer Service Peace Corps Act: or a volunteer under the Domestic Volunteer Service Act of 1973
_____________________________________________________________________________________________________
Employer (School Name and District if applicable)
Address Ci t y State ZIP Phone
Signature of Authorized Official Tit le Dat e