First Name: Student ID:
City, State, Zip:
Last Name:
Appeal Committee Decision
Approved Please allow a minimum of ten working days for your academic and/or tuition balance records to
be updated. You can check your account and/or academic record status via your eservices account.
A decision cannot be made at this time.
Denied Your request was not approved. The circumstance described in your appeal is not a reason where
an exception to policy can be approved.
The student is responsible for knowing and complying with NHCC policies and procedures including the college
drop, withdraw and refund policy. Student error or misunderstanding of the drop and/or withdraw process is not a
reason where an exception to policy can be approved.
The appeal deadline has passed.
Request must be accompanied by medical documentation written and signed by your health care professional on
letterhead. It must clearly identify any dates that correlate with the situation(s) that prevented you from attending
Medical appeals are only considered for significant, unanticipated student illness (or with appropriate
documentation, direct dependents of the student). The situation described in the appeal is not one where a
medical appeal request can be approved.
The required documentation was not provided.
your request is currently within the appeal deadline and you have additional documentation to add to your appeal, send
the additional information to the Advising Center and request a second review.
you have questions regarding the appeal decision, please call 763.424.0703
Office Use:
Accounting and Fees
Financial Aid
No Review Needed
Refund %
Due to:
No Review
Change courses to W:
Courses Approved: Term: F S SS
7411 85
Avenue North
Brooklyn Park, MN 55445-2299
Advising Center 763-424-0703
Financial Aid 763-424-0728
You MUST meet with an advisor to complete this form
North Hennepin Community College
Appeal Tuition and/or Late Withdraw
Appeal Instructions:
STEP 1: Contact the Advising Center to meet with an advisor to complete this form and to review your situation and identify
the required documentation. 763-424-0703.
Advisor Signature: Date:
P 2: Identify the semester, type of request and classes to be reviewed:
Summer 20____ Fall 20____ Spring 20____
Late Withdraw Tuition Refund
List Class(es):
STEP 3: Rationale for appeal and required documentation. Appeals without relevant documentation will be denied.
Major Medical Issue an unexpected, significant medical condition prevented attendance.
Documentation needed:
Healthcare provider statement (signed and written on letterhead) that clearly identifies the dates
and the situation that prevented you from attending classes. Do not provide copies of bills,
appointments, prescriptions, etc.
College Error
Documentation needed:
College materials documenting the error or an employee written statement describing the
Military Call to Active Duty (a late drop may be requested if due to military call-up to active duty)
Documentation needed:
Copy of DD-214
Documentation needed:
Documentation that supports your request and that the circumstances were unforeseen and
beyond your control or choice.
P 4: Provide a written statement (one page maximum) describing the situation in detail.
P 5: Read and sign below:
I have read and understand:
Late withdrawals can result in aid recipients being required to repay financial aid for the semester.
The appeal deadline is 30 days after the appeal term ended.
Appeal results will be emailed to the email address above within 14 business days.
Requests based on the following situations will not be considered:
o Lack of knowledge of drop, refund,
withdrawal or other college policies
o Dissatisfaction with faculty, class or grade
o Voluntary acceptance of employment or
other activity impacting ability to attend
o Disregarding course/placement requirements
o Change in marital or relationship status
o Did not attend course(s)
o Incarceration or arrest
o Inability to pay
Student Signature: Date:
STEP 6: Return this form and the required documentation to the Advising Center, ES-69
Questions? Call Advising at 763-424-0703 or email
7411 85th Avenue North • Brooklyn Park, MN 55445 • Phone: 763-424-0702 • Fax: 763-424-0929 • Email: • Web:
Member of the Minnesota State Colleges and Universities System and Equal Opportunity Educator and Employer
For disability accommodations call 763-493-0555, Minnesota Relay users may call 1-800-627-3529