2020 - 2021 Agency Payment Pending
D No:_______________________
Name: ___________________________________ Date of Birth: _________________
(Print Only)
lease select only one Term _____ Summer 2020 _____ Fall 2020 _____ Spring 2021
____WIOA Agency Funding is pending Agency Name__________________________
____TAA Agency Funding is pending
____DVR Agency Funding is pending Authorizing Person______________________
____WI GI Bill Funding is pending
____Other____________________________ Phone No
I understand that I am liable for the full payment of fees. I agree to pay Lakeshore Technical College the balance
deferred if the anticipated funding as stated in this agreement is not received for any reason. Attendance records
will not affect the amount due. Initial Please_________
Official withdrawals and requests for refunds
or adjustments must be made in writing to Student Records at LTC-
Cleveland. If you do not officially withdraw from a class, you will be responsible for full payment of that class according to
the refunding policy below.
If I officially withdraw from class(es) or school, I will be granted a refund (or receive a fee adjustment) in accordance with
the Wisconsin Technical College System Board Refund Policy which states: students enrolling in courses are entitled to
fee refunds equal to 80 percent of the fees if they withdraw before or at the time 10% of the course’s potential hours of
instruction have been completed. If students withdraw after 10% but before more than 20% of the course’s potential hours
of instruction have been completed, they are entitled to a fee refund equal to 60 percent of the fees. If students withdraw
after 20% of the course’s potential hours of instruction have been completed, they are not entitled to a fee refund. No
refunds will be considered for advanced standing test out or placement fees.
Time Remaining in Class Refund Percent
99-90% ......................................... 80%
89-80% ......................................... 60%
Less than 80% ............................... 0%
I understand the following:
Depending on the timing of my registration, I may not receive a bill prior to the payment due date
Any amount not paid by due date will result in a late fee of $100
Accounts over 120 days past due will be turned over to a collection agency. Accounts will also be sent to the
State of Wisconsin Tax Refund Intercept Program (TRIP) or State Debt Collection (SDC).
My student file will be restricted and no further enrollment will be permitted on present and future terms.
I will not receive grade reports or degrees.
Requests for official transcripts will be denied until balance due is paid in full.
If payment method is returned for insufficient funds or other reason, my account will be assessed a $25 fee.
_____________________________________________ ______________________
(Student Signature) (Date)
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