REQUEST FOR PARTIAL CANCELLATION ON THE FEDERAL
PERKINS/NATIONAL DIRECT STUDENT LOAN PROGRAM
 
PART I: TO BE COMPLETED BY BORROWER
 
Account Number:                                                                       Check if new address ___ 
Name (Last, First, State & Zip Code) 
_______________________________________________________________________________ 
THIS IS TO CERTIFY THAT I HAVE BEEN (CHECK ONE ITEM) 
______ VOLUNTEER SERVICE CANCELLATION (Peace Corps, Domestic Vol. Service) 
______ LAW ENFORCEMENT OR CORRECTIONS OFFICER CANCELLATION 
______ NURSE OR MEDICAL TECHNICIAN CANCELLATION 
______ CHILD OR FAMILY SERVICE AGENCY CANCELLATION 

From (Month & Year) ____________ To (Month & Year) ______________ 

I Declare that I was Employed Full-Time for the above listed time period.  I agree to notify 
the University of Maryland, College Park, immediately upon termination of my claimed status. 

_____ Check here if you expect to be eligible for cancellation again and if so through 
           what date:    MONTH_______ YEAR_______ 

SIGNATURE OF BORROWER_______________________________ DATE_____________ ========================================================================  
PART II: TO BE COMPLETED BY CERTIFYING AUTHORITY 
I CERTIFY THAT THE INFORMATION ABOVE IS TRUE AND CORRECT 

Signature of Certifying Official                                           Date 
___________________________________                      ________________ 
Name of Organization                                                         Official Seal or Stamp 
                                                                                           (if none include signed 
Address of Organization                                                      letter of certification) 

Phone number 

========================================================================  
PART III: UNIVERSITY OF MARYLAND ACTION: APPROVED__ DISAPPROVED__ ---------------------------------------------------------------------------------------------------------------------- 
Approved At: _ 15% _ 15% _ 20% _ 20% _ 30% 
Loan Principal Canceled Interest Canceled Total Canceled New Balance
Due Fields To Be Cleared Next Bill Date Postponement Ends
Signature of Approving Officer________________________________________ 

Title___________________________ Date _______________ 

Return Completed Form To: 

THE UNIVERSITY OF MARYLAND
OFFICE OF THE BURSAR
LEE BUILDING
COLLEGE PARK, MD 20742-5151