Cancellation 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: ACCOUNT NUMBER: 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 ____ Staff member performing qualified service under the Headstart Act  Section B ____ Special Education Teacher or qualified provider of Early Intervention Services  Section C ____ Law Enforcement/Corrections Officer for an eligible Local, State, or Federal Agency (after 11-29-90)  Section D ____ Teacher of Mathematics, Science, Foreign Languages, Bilingual Education (loans after 7-23-92)  Section E ____ Nurse – must provide copies of License/Certification  Section F ____ Medical Technician – must provide copies of License/Certification  Section F ____ Service agent providing or supervising the provision of services to High Risk Children for Low-Income Communities and Families of such children (after 7-23-92)  Section G Section 2 Certification Period Please complete all of the following that applies: Postponement (for THIS or NEXT year) – Starting date________________ Ending date____________________ Cancellation   (for PREVIOUS year)       - Starting date____________________ Ending date____________________ 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 my lender or Educational Computer Systems, Inc. immediately upon any change in my status.   Signature of borrower____________________________ Date___________ Day Phone_____________ Evening Phone______________ Section 4 Certification by School / Agency / Institution I certify that the information stated above is true and correct. Employed by school district____________________________________________________ County__________________________ School name_______________________________________________ Address_________________________________________ City____________________________________________________ State__________ Zip____________ Phone_______________ Description of Exact Duties (attach sheet if necessary)_______________________________________________________________ Signature of Authorized Official_____________________________________________________ Date_______________________ Title ___________________________________________________________________________________________________ Canc. Rev. 10-99 ECSI INVALID WITHOUT OFFICIAL SEAL, STAMP OR LETTERHEAD FOR INSTITUTIONAL USE ONLY Approved_____ Disapproved_____ Official Name_________________________________________ Date______________________ Please return this form within the next (10) days to claim exemption of payment and eliminate past due notice.  This form will be returned to the borrower if it is incomplete. Heartland ECSI PO Box 1278 Wexford, PA  15090 11/22/1999