Louisiana Delta Community College
7500 Millhaven Road
Monroe, LA 71203
318-345-9003
318-345-9006 FAX
www.ladelta.edu
TITLE IV AUTHORIZATION AND PRIOR TERM CHARGES FORM
INSTRUCTIONS:
Federal regulations require authorization from the student to use Title IV funds (i.e., federal financial aid) to pay prior term
and/or current term non-educational charges within the same academic year (i.e. Fall, Spring, Summer). Without my
permission, my federal aid will pay only educational charges. I acknowledge that I will be responsible for any charges that
Title IV funds and other funds will not cover. I understand I may not receive any refunds from federal aid until I pay all
charges owed to the college.
NOTE: Please check your LoLA account to determine your account balance.
A. STUDENT INFORMATION
Student Name: _________________________________
Student ID #:
_________
Mailing Address:
______________________________ Telephone Number: __________________________
Email
Address: _______________________________ DOB: ____________________________________
B. AUTHORIZATION
Please select an option be
l
ow:
I voluntarily authorize the college to credit all Title IV funds to my student account to pay
current
educational charges, non-educational charges (i.e. PARKING DECAL) and prior YEAR
charges not to exceed
$200.00. I understand this authorization will remain valid while
enrolled at the college, and I may cancel this authorization, in writing, at any time.
I do NOT authorize the college to credit Title IV funds to pay current non-educational
charges (I.e. PARKING DECAL) as well as prior term charges within the same academic
year. I understand I will pay for these charges myself before receiving any refunds and
failure to do so may result in deletion of my classes.
Student
Signature
: ________________________
Date
:
______
click to sign
signature
click to edit
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