Fillable DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE

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DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE

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DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE
Special form is available for medical absences or withdrawals requiring certification by attending physician.
Tuition Refund Plan
DISMISSAL OR WITHDRAWAL CERTIFICATE
To be completed by the parent or guardian
Date _______________________________
I HEREBY CERTIFY to A. W. G. DEWAR, INC. that ___________________________________ has severed his/her
(Student’s name)
connection with ______________________________________________ School/College as of ____________________ .
(DATE)
I acknowledge that this student has attended at least fourteen consecutive calendar days from the student’s first
class day of attendance in the academic year. In addition, we acknowledge that the withdrawal of the student
is for the remainder of the academic year and accordingly the student will not return to the school during
the current academic year.
Reason(s) for withdrawal or dismissal: ________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I hereby authorize A. W. G. Dewar, Inc. to make settlement payable to the above School/College, such settlement
to be credited to my account, with any excess to be remitted to me through the School/College.
PLEASE SEE THE REVERSE SIDE OF THIS FORM FOR IMPORTANT
FRAUD INFORMATION REGARDING YOUR CLAIM.
Parent or
Legal Guardian or
Person Financially Responsible: ____________________________________________________
(SIGNATURE)
Address: ____________________________________________________
Telephone #: __________________________________
Note: This form must be returned to the School/College for transmittal to A. W. G. DEWAR, INC. as soon as
possible, in any event, not later than 30 days after date of withdrawal or dismissal.
G41603 03 11
IMPORTANT NOTICE
To Arizona Claimants
For your protection Arizona law requires the
following statement to appear on this form.
Any person who knowingly presents a false
or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
TO CLAIMANTS IN ARKANSAS, LOUISIANA,
MARYLAND AND TEXAS,
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT
OR (in AR, LA or MD) KNOWINGLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS
GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.
To California Claimants
For your protection California law requires the
following to appear on this form: Any person who
knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be
subject to fines and confinement in state prison.
To Colorado Claimants
It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance
company for the purpose of defrauding or attempting
to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an
insurance company who knowingly provides false,
incomplete, or misleading facts or information to a
policyholder or claimant for the purpose of defrauding
or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado
division of insurance within the department of
regulatory agencies.
To Claimants in Delaware, Idaho and Indiana
Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony.
To Florida Claimants
Any person who knowingly and with intent to injure, defraud, or
deceive any insurer, files a statement of claim containing any false,
incomplete, or misleading information is guilty of a felony of the third
degree.
To Kentucky Claimants
Any person who knowingly and with intent to defraud any insurance
company or other person files a statement of claim containing any
materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime.
To Minnesota Claimants
A person who files a claim with intent to defraud or helps
commit a fraud against an insurer is guilty of a crime.
To New Hampshire Claimants
Any person who, with a purpose to injure, defraud or deceive any
insurance company, files a statement of claim containing any false,
incomplete or misleading information is subject to prosecution and
punishment for insurance fraud, as provided in RSA 638:20.
To New Jersey Claimants
Any person who knowingly files a statement of claim containing any
false or misleading information is subject to criminal and civil
penalties.
TO NEW MEXICO CLAIMANTS
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT
OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND
MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
To New York Claimants
Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or
statement of claim containing any materially false information, or
conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to exceed five
thousand dollars and the stated value of the claim for each such
violation.
To Ohio Claimants
Any person who, with intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files
a claim containing a false or deceptive statement is guilty of
insurance fraud.
To Oklahoma Claimants
WARNING: Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of
an insurance policy containing any false, incomplete or misleading
information is guilty of a felony.
To Oregon Claimants
Any person who knowingly and with the intent to defraud any
insurer provides false or misleading information concerning any fact
material to a risk to be insured or to a claim for loss or benefits may
be guilty of a crime.
To Pennsylvania Claimants
Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or
statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
To Claimants in Virginia, Washington and any
State not listed above
It is a crime to knowingly provide false, incomplete, or misleading
information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines or a denial of
insurance benefits.
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DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE

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Completed 7 December 2020

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