Student Accounts Office • SUNY Plattsburgh • 101 Broad Street • Plattsburgh, NY 12901-2681
Tel: (518) 564-3120 • Fax: (518) 564-3116 • email: email@example.com
Revised: 12/01/2019 PRIOR
AUTHORIZATION TO PAY OUTSTANDING BALANCE WITH ANTICIPATED REFUND
Student Name: ___________________________ Banner ID or NetID: ____________________________
Students sometimes have outstanding account balances from a prior term and an anticipated refund in the
current term or an upcoming term. Students complete this form in order to request and authorize Student
Financial Services to use an anticipated refund to pay an outstanding balance from a prior term.
If this request involves federal financial aid, federal regulations only allow the college to perform this transfer
when the anticipated refund occurs within the same academic year as the prior balance. If the prior balance
and anticipated refund are from different academic years, then the student will need to pay the prior balance
after the refund is disbursed to them.
In the table below, indicate the semester and amount of your outstanding balance:
In the table below, indicate the semester and amount of the anticipated refund that you are requesting to apply
toward your outstanding balance.
AUTHORIZATION AND SIGNATURE
By signing below, I authorize SUNY Plattsburgh to transfer the funds from the anticipated refund (specified
above) toward my outstanding balance (specified above) after disbursement. By signing below, also I
acknowledged that my actual refund for the above semester will be reduced by the amount of this transfer. If I
become ineligible for this anticipated refund, I understand that this request will become invalid and I will be
responsible for paying the outstanding balance from other sources.
The parent borrower signature is required if this request involves a federal Parent PLUS Loan.
Student Ink Signature Date
Parent Borrower Ink Signature (only for PLUS Loans) Date