Request Form For Cancellation
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1WASHINGTON STATE UNIVERSITY
University Receivables Student Loans
PO Box 641039 (OPE#003800)
Pullman Wa 99164-1039 (509)335-9651
REQUEST FOR CANCELLATION
PART I--TO BE COMPLETED BY BORROWER
WSU ID#
__________________
Home Phone
_______________
Borrower Name __________________
Business Phone
_______________
Address
__________________________________________________________
E-Mail
__________________
This is to verify that I have been (check appropriate item. Refer to promissory note)
{ } Full time Teacher (school must qualify) Low income.
{ } Full time Teacher, handicapped
{ } Full time worker for Head Start
{ } Full time Teacher, science, math, foreign language
{ } Full time Nurse or Medical Tech (include detailed job description)
{ } Law Enforcement (include detailed job description)
{ } Peace Corps or Domestic Volunteer (include detailed job description)
{ } Family Service Provider (include detailed job description)
Dates of Service (From)_______________(to)_________________
I request cancellation of the appropriate amount of principal and
interest for such service in accordance with my Education under the
Law and in accordance with Regulations and Instructions issued by
the U.S. Commissioner of Education.
{ } I intend to continue my employment for the next year
(From)______________(to)_______________
{ } I do not intend to continue my employment next year.
Borrower Signature:__________________________________Date:_____________________
Part II --CERTIFICATION BY THE BORROWER’S EMPLOYER
I certify that the borrower’s declaration as to his/her employment. The
completion of his/her service and the description of his/her duties are true
and correct.
Employing Agency
_____________________________
School Dist. & School Name
_____________________________
Address
_____________________________
Phone
_____________________________
Signature of Authorized Official
_____________________________
Title
_____________________________
Date
_____________________________
PART III-- COMPLETED BY WASHINGTON STATE UNIVERSITY
{ } 15% Rate
{ } 20% Rate { } 30% Rate { } Disapproved
Principal Canceled_____________ ______________Interest Canceled________________
Total Amount Canceled________________________Balance _______________________
Reason for Disapproval______________________________________________________
_________________________________________________________________________
Signature of Approving Official________________________________________________
Title_______________________Date___________________________
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