Fill - Free fillable APPEAL OF 3 ATTEMPT FULL COST OF INSTRUCTION (Palm Beach State College) PDF form

Rev. 2/10

Location:  Belle Glade  Boca Raton  Lake Worth  Palm Beach Gardens

APPEAL OF 3

ATTEMPT FULL COST OF INSTRUCTION TUITION

PLEASE READ CAREFULLY (only for courses for which an insufficient grade was received)

Florida Statutes place responsibility for the full cost of instruction (out-of-state tuition) on the student after the second attempt of a

course. The legislation also provides students the opportunity to appeal for a one-time exception, per course, to the increased fees

for cases involving major extenuating circumstances beyond the student’s control. Such circumstances include, but are not limited

to:

 serious illness;

 documented medical condition preventing completion;

 death of an immediate family member (father, mother, sister, brother);

 involuntary call to active military duty;

 documented learning disability;

 English as a second language background;

 documented change in conditions of employment; and/or

 other emergency circumstances or extraordinary situations (such as national disasters).

Also, students may appeal the increase in fees based on financial hardship. The criteria for determining financial hardship shall

include, but not be limited to, qualifications for federal need-based financial aid. All appeals are considered on an individual basis.

Note: NO APPEALS will be considered AFTER the last day of add/drop.

1. Course __________________________________________ Term/Year of Last Attempt_____________

Documentation of emergency, extraordinary situation or financial hardship is required.

This section is to be completed by the STUDENT. Submit form/documentation to the Campus Registrar.

NAME: ________________________________________ STUDENT ID: __________________ TELEPHONE (____) ______________

ADDRESS ________________________________________________________________________________________________________

Street City State Zip Code

COURSE(S) FOR WHICH THIS APPEAL IS BEING FILED:

2. Course __________________________________________ Term/Year of Last Attempt_____________

3. Course __________________________________________ Term/Year of Last Attempt_____________

JUSTIFICATION FOR APPEAL (Documentation must accompany form): _______________________________________________________

_________________________________________________________________________________________________________________

Student’s Signature: __________________________________________________ Date: ___________________________

This section to be completed by College Personnel

ACTION:  Approved  Disapproved  Referred DATE: ______________________

PROCESSED BY: ___________________________________

COMMENTS:__________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

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