Fillable AUTHORIZATION TO PAY OUTSTANDING BALANCE WITH ANTICIPATED REFUND (State University of New York at Plattsburgh)

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AUTHORIZATION TO PAY OUTSTANDING BALANCE WITH ANTICIPATED REFUND (State University of New York at Plattsburgh)

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Student Accounts Office • SUNY Plattsburgh • 101 Broad Street • Plattsburgh, NY 12901-2681
Tel: (518) 564-3120 • Fax: (518) 564-3116 • email: myaccount@plattsburgh.edu
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.
OUTSTANDING BALANCE
In the table below, indicate the semester and amount of your outstanding balance:
Semester
Amount
☐ Fall 2020
$
☐ Winter 2021
$
☐ Spring 2021
$
☐ Summer 2021
$
☐ Other:_______________
$
ANTICIPATED REFUND
In the table below, indicate the semester and amount of the anticipated refund that you are requesting to apply toward
your outstanding balance.
Semester
Amount
☐ Fall 2020
$
☐ Winter 2021
$
☐ Spring 2021
$
☐ Summer 2021
$
☐ Other____________
$
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
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Completed 1 February 2021

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