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Cancellationrequestduetoemployment

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U.S.A. forms for Louisiana State University

BROWSE LOUISIANA STATE UNIVERSITY FORMS

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Page 1 of 2
125 Thomas Boyd Hall • Baton Rouge, LA 70803 • P 225-578-3092 • F 225-578-3969 • perkinsloan@lsu.edu
Louisiana State University
Office of Accounting Services
Bursar Operations – Perkins Loan
125 Thomas Boyd Hall
FEDERAL PERKINS LOAN PROGRAM – CANCELLATION REQUEST DUE TO EMPLOYMENT
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or on any accompanying
documents shall be subject to a fine of no more than $10,000 or imprisonment for not more than five years or both, under the
provision of Sec. 20 U.S.C. 1097.
SECTION 1: BORROWER INFORMATION (To be completed by the borrower)
Name: _______________________________________________________ LSUID: ___________________________
Mailing Address: ____________________________________________________________________________________
City: __________________________________________________ State: _______________ Zip Code: ____________
E-mail: ____________________________________________________ Phone Number: _________________________
Cancellation Period Requested: From: (MM/DD/YEAR) _________________ To: (MM/DD/YEAR) __________________
I certify that I am eligible for cancellation of repayment because I am a (check the appropriate field):
Head Start Teacher/Pre-Kindergarten/Child Care
Nurse/Medical Technician
Teacher at a school with a high concentration of
low-income students
Family Service Agency Employee
Special Education Teacher
Peace Corps Volunteer
Teacher of the Handicapped
VISTA Volunteer
Early Intervention Service Provider
Member of Armed Forces - Hostile Area
Teacher in a Shortage Field
Law Enforcement/Corrections Officer
Faculty at a Tribal College or University
Firefighter
Speech Language Pathologist with master’s degree
working exclusively with Title I eligible schools
Librarian with a master’s degree in Library
Science employed at Title I funded school or
public library serving low income area
I declare that the information shown above is true and correct and that I will immediately notify the LSU Perkins Loan
office upon any change in my status. I further understand that if, for any reason, I am not eligible for the requested
cancellation or the appropriate forms are not submitted in a timely manner, payment of both principal and interest for
the elapsed months will become immediately due and payable.
_____________________________________________ ______________________________
Signature of Borrower Date
***Section 2, on the back of this form, must be completed prior to submitting***
----------------------------------------------------------------------------------------------------------------------------------------------------------------
FOR ACCOUNTING SERVICES USE ONLY
Approved Disapproved Inclusive Dates of Approval: From: (MM/DD/YEAR) ________________ To: (MM/DD/YEAR) ______________
Reviewed by __________________________________________________________ Date _______________________________
Page 2 of 2
Louisiana State University
Office of Accounting Services
Bursar Operations – Perkins Loan
125 Thomas Boyd Hall
SECTION 2: AUTHORIZED OFFICIAL’S CERTIFICATION (to be completed by the Organization, School, Official or Agency)
Name of Organization: ______________________________________________ Phone Number: ____________________________
Mailing Address: ______________________________________________________________________________________________
City: __________________________________________________ State: ____________ Zip Code: _________________________
I certify that the information stated in Section 1 (on reverse) is true and correct. The person named provides the service in the
following checked statuses.
____ Full time teacher at ________________________ (Name of School) which is listed by the U.S. Department of Education as having a high
concentration of low-income students. The teacher at the aforementioned school may be employed by an educational service agency and
the school or location may be one that is operated by an educational service agency.
_____ Full time teacher of handicapped children in a public or non-profit elementary or secondary school system. The majority of the students
whom the borrower teaches are handicapped children.
_____ Full time staff member in a Head Start program. This program operates for a complete academic year and the borrower’s salary does not
exceed the salary of a comparable employee working in the local educational agency of the area served by the Head Start program. Also,
full time staff members in a pre-kindergarten or childcare program that is licensed or regulated by the state.
_____ Full time special education teacher, including teachers of infants, toddlers, children, or youth with disabilities in a public or other non-
profit elementary or secondary school system.
_____ Full time qualified professional provider of early intervention services in a public or other non-profit program under public supervision.
_____ Full time teacher of mathematics, science, foreign languages, bilingual education, or any other field of expertise that is determined by the
state and education agency to have a shortage of qualified teachers. Specify subject matter and grade level teaching
___________________________________________________________.
_____ Full time nurse or medical technician. Official job title: ____________________________________. Include job description.
_____ Full time employee of a public or private non-profit child or family service agency who is providing or supervising provision of services to
high risk children and their families from low income communities.
_____ Full time Peace Corps or VISTA volunteer.
_____ Full time Law enforcement or corrections officer for an eligible agency that is a publicly funded unit, whose principal activities pertain to
crime prevention, control or reduction or the enforcement of the criminal law. This includes, but is not limited to police efforts to prevent,
control or reduce crime or to apprehend criminals; activities of courts having criminal jurisdiction and related agencies; activities of
corrections, probation or parole authorities; and problems relating to prevention, control or reduction of juvenile delinquency or narcotic
addiction. The borrower must be a sworn officer or person whose principal responsibilities are unique to the criminal justice system and
are essential in the performance of the agency’s primary mission.
_____ Full time service in the U.S. Armed Forces in an area of hostilities that qualifies for special pay under Sec. 310 of Title 37 of the U.S. Code.
_____ Full time speech-language pathologist with a master’s degree who is working exclusively with Title I eligible schools.
_____ Librarian with a master’s degree in Library Science who is employed in an elementary or secondary school that qualifies for Title I funding,
or in a public library that serves a geographic area that includes one or more Title I schools.
_____ Full time faculty member at a Tribal College or University
_____ Full time firefighter with a local, state or federal fire department or fire district.
The inclusive dates for which I am certifying this borrower’s status are:
FROM: (MM/DD/YEAR) ______________
TO: (MM/DD/YEAR) ______________
______________________________________
Signature of Certified Official
______________________________________
Print Name and Title
_______________________ _________________________________
Date Official Seal or Stamp Required
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Cancellationrequestduetoemployment

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Completed 16 November 2019

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