Collegewide Tuition Refund/Credit Request Form
Name: ___________________________________________________________________________________________
EFSC ID Number: _______________________________________________Term:______________________________
Address: _________________________________________________________Phone:__________________________
City: ___________________________________________ State: _____________________Zip:___________________
Requesting credit for: All courses
Only Courses Listed
Check the box below for the appropriate reason. Verifying documentation is required.
F
ees may be refunded for circumstances that are exceptional and beyond the control of the student.
100% refund to student called to or enlisted in active military duty. Copy of military orders must be provided.
100% refund due to the death of the student.
Fees may be refunded or Tuition Credit issued for circumstances that are exceptional and beyond the control of
the student. Tuition credit is nonrefundable and non-transferable.
Up to 100% tuition credit due to the documented death in immediate family of student. Copy of death certificate or letter
from clergy/attorney must be provided.
Up to 100% tuition credit due to the documented serious illness or serious accident of the student. Note from
physician/surgeon’s office must be provided.
Up to 100% tuition credit due to other emergency circumstances or extraordinary situations in accordance with
operational procedures.
I understand that exceptions may be referred to the Student Financial Appeals Committee (SFAC). The decision of
the SFAC is final.
Signature of the student
or person making request:___________________________________________________ Date:_____________________
SCA-087 R030719 White ltr Distribution: Original to Accounting, copy to Associate Provost/Dean and Student
PREFIX
NUMBER
SECTION
TITLE
Associate Provost/Dean Use
Denied Approved Documentation on file in Associate Provost Office
Reason: _______________________________________________________________________________________
Signature:______________________________________________________________ Date:___________________
Accounting Use
Action Approved: Tuition Credit ____________Current Account Balance_____________ Future Tuition_____________
Comments:_______________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Admissions/Registrar Signature: _______________________________________________Date:__________________
Action___________________________________________________________________________________________
Accounting Personnel’s Signature: _____________________________________________Date:___________________
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