Soar in 4: Governor’s Challenge Program
Denial of Rebate Re-evaluation Form
Upon receiving notice that you have not met the criteria to receive a tuition rebate, you can request a re-evaluation of your
Rebate Application within one month of receiving your denial. This re-evaluation can be based upon extenuating
circumstances or documented University error. A committee consisting of a representative from each of the following offices:
the Soar in 4 Program, the Academic Advising Community, Career Development Services, Internships and Co-operative
Programs and the Office of the Bursar, will re-evaluate your application. An outcome notification will be sent to you once
this re-evaluation is completed that will explain how the committee arrived at its decision to approve or deny your appeal.
Section I: General Student Information
The below section is to be completed and signed by the student prior to submission.
Student Name
Phone Number
Permanent E-Mail Address
First Term of Enrollment (Example: Fall 2015)
Graduation Term (Example: Spring 2019)
Degree (Example: Bachelor of Arts in Psychology)
Section II: Requirement Non-Compliance
Please select the requirement(s) with which you have not complied as a requirement of the Soar in 4 program.
I did not select a major in my first year
I did not receive academic advising at FGCU during my first year
I did not receive academic advising at FGCU during my second year
I did not receive academic advising at FGCU during my third year
I did not receive academic advising at FGCU during my fourth year
I did not participate in an internship, co-op work experience, or another similar opportunity
I did not participate in a one-on-one appointment with Career Development Services
I did not participate in a recruitment event hosted by Career Development Services
I did not obtain a full-time job in the State of Florida within 6 months of graduation earning at least $25,000/year
I did not submit my Rebate Application within one year of graduation
Section III: Nature of Appeal
Please select the reason(s) that best describe your noncompliance with the above referenced requirement. Include the
appropriate documentation for the nature of your appeal, which can be found on the next page of this document.
Financial Circumstances
Physical or Psychological Illness or Injury
Serious Illness or Injury of an Immediate Family Member
Death of an Immediate Family Member
University Error
Other Circumstance Not Described
For Financial Circumstances: You must provide documentation which shows that you have experienced an unexpected
change in your financial circumstances which was outside your control. This may include evidence of you or an immediate
family member who was financially supporting you losing a primary job; evidence of large, unanticipated medical expenses;
or a documented change in family status that has reduced your anticipated financial support. Please note that voluntarily
leaving a job, being terminated for cause, choosing not to use financial resources available to you, or irresponsible spending
are not considered to be extenuating circumstances.
For Illness or Injury Circumstances: You must include documentation from a licensed medical or mental health provider.
Documentation must include information about the medical or psychological condition that is necessitating request for re-
evaluation. All medical documentation may be verified with the issuing provider.
For a student injury or illness (Self): A student must provide documentation of an injury or illness which was not
previously known to the student, or which was believed to have been previously treated and resolved or evidence that
they have experienced an escalation, decline or “flare-up” of the condition of its symptoms. On-going conditions which
were known to the student must have documentation of an escalation, decline, or “flare-up” to be considered.
For injury or Illness (Family Member): A student must provide evidence to demonstrate that an Immediate Family
Member has sustained or developed a new Injury or Illness or has experienced an escalation, decline or “flare-up” or
a previously existing condition. Additionally, the student must provide documentation of the impact of this new or
changing condition, such as their role in providing care for the Family Member or care for the minor children of the
Family Member.
For Death of an Immediate Family Member Circumstances: Please include a copy of the signed death certificate as well
as a funeral program or obituary listing you as a surviving relative, or other documentation showing your familial connection
to the deceased. Please be aware that, while FGCU recognizes there is no universal definition of family, federal regulations
limit immediate family to a Parent, Spouse, Sibling or Child for financial purposes. The Florida Board of Governors defines
Immediate Family as a Child, Grandparent, Parent, Sibling, or Spouse. The committee may also choose to consider persons
who are similarly situated, such as a domestic partner, person with a custodial interest in the student (foster parent, aunt or
uncle with whom the student permanently resides, etc.) or a minor person for whom the student serves as a guardian.
For University Error: An appeal due to university error must be submitted with supporting documentation signed by a
dean, department chair, or other university official confirming that there was an error which caused the student to have not
complied with the aforementioned requirement of the Soar in 4 program.
For Other Circumstances Not Described: Are you requesting a re-evaluation based on a type of extenuating circumstance
not listed on this form? If so, describe clearly in the box below and attach appropriate supporting documentation. These
appeals will be reviewed on a case-by-case basis by the committee.
Section IV: Personal Statement
Please select the requirement(s) with which you have not complied as a requirement of the Soar in 4 program.
Regardless of the type of appeal you are filing, you MUST submit a personal statement. This will be your ONLY opportunity
to address the committee directly, so please take your time and provide a complete explanation of your circumstances, any
relevant background information, and any necessary explanation of the supporting documents you will be attaching.
Please attach your personal statement, along with your supporting documentation, to this Denial of Rebate Re-evaluation
Section V: Denial of Rebate Re-evaluation Form Review
By submitting this form to the Denial of Rebate Re-evaluation Committee, you confirm that you have completed all sections
of this form and understand that submitting this form with any section left uncompleted will result in an automatic denial.
Please type your name below to certify that all information presented in this request to re-evaluate your Rebate Application
for the Soar in 4 program is, to the best of your knowledge, accurate and truthful. By typing your name below, you also
acknowledge that this will be the only opportunity granted for the committee to re-evaluate your Rebate Application and all
outcomes are final.
Student Name Date
Section VI: For Committee Use Only
This Section is for Committee Use Only
Committee Signatures
Soar in 4
Academic Advising Community
Career Development Services
Internships and Co-operative Programs
Office of the Bursar