Tennessee Tech University
Request for HeadStart Cancellation
Please return this form immediately. Incomplete forms will not be accepted
Name/Address __________________________________________________________ MAIL FORM TO: Tenn Tech University
__________________________________________________________ Loan Accounting
__________________________________________________________ PO Box 5037
__________________________________________________________ Cookeville, TN 38505
E-mail Address _____________________________________________________ Account Number: ____________________
Day phone ________________________ Evening phone ________________________ Cell phone ____________________
Lending Institution TENNESSEE TECHNOLOGICAL UNIVERSITY OPE# 00352300
Section 1 Request for Cancellation
I hereby apply for cancellation of a portion of my Federal Perkins student loan(s). I was a full-time staff member of a HeadStart
program for a full year.
Section 2 Certification Period
My full year of HeadStart work began _________________ ended ________________
|__| I will continue HeadStart work next year
if for any reason I am unable to complete the YEAR of service, I will begin repayment of my loan, including all postponed, current
and past due payments immediately
Section 3 Borrower Signature
I declare that the information above is true and correct. i further declare that I will notify Tenn Tech Univ immediately upon any
change in my status.
Date__________________________________ Signed ___________________________________________
Section 4 Certification by School/Agency/Institution
I certify that the information sated above is true and correct
Employed by school, dept. or agency
County ________________________ Address _______________________________________________
City __________________________ State _______ Zip _____________ Phone ____________________
Description of Exact Duties _________________________________________________________________
Signature of Authorized Official _______________________________________ Date __________________
Printed Name and Title _____________________________________________________________________
** IF SEAL OR STAMP IS NOT AVAILABLE, LETTERHEAD MUST BE ATTACHED STATING THAT NO SEAL/STAMP IS
AVAILABLE
For institutional use only
% Canc ________ Amt Canc $ ___________ Official Name __________________________ Date _________
