Employee Reimbursement Payment Pending
ITEMS REQUIRED: LTC Employer Reimbursement Payment Pending Form, Employer Reimbursement Policy, $50 Down Payment per class
Accounts with past due balances are exempt from this payment plan.
Payment in full six weeks
after final class end date
I understand that I am liable for the full payment of fees. I will pay $50 per class down payment I agree to pay Lakeshore
Technical College the balance deferred if the anticipated funding as stated in this agreement is not received for any reason.
Official withdrawals and requests for refunds or adjustments must be made in writing to Student Records at LTC-Cleveland. If
you do not officially withdraw from a class, you will be responsible for full payment of that class according to the refunding
If I officially withdraw from class (es) or college, I will be granted a refund (or receive a fee adjustment) in accordance with the
Wisconsin Technical College System Board Refund Policy which states: students enrolling in courses are entitled to fee refunds equal
to 80 percent of the fees if they withdraw before or at the time 10% of the course’s potential hours of instruction have been completed.
If students withdraw after 10% but before more than 20% of the course’s potential hours of instruction have been completed, they are
entitled to a fee refund equal to 60 percent of the fees. If students withdraw after 20% of the course’s potential hours of instruction have
been completed, they are not entitled to a fee refund. No refunds will be considered for advanced standing test out or placement fees.
Time Remaining in Class Refund Percent
99-90% .............................................. 80%
89-80% .............................................. 60%
Less than 80% ..................................... 0%
I understand the following:
• Any amount not paid by due date will result in a late fee of $100 per semester.
• Accounts over 120 days past due will be turned over to Wisconsin State Debt Collection (SDC) or State of Wisconsin Tax Refund Intercept
Program (TRIP) depending on amount owed to LTC outstanding.
• My student file will be restricted and no further enrollment will be permitted on present and future terms.
• Requests for official transcripts will be denied until balance due is paid in full.
• If payment method is returned for insufficient funds or other reason, my account will be charged $25.
(Student Signature) (Date)
Email form along with employer reimbursement policy to firstname.lastname@example.org.
Employer Contact and Phone
click to sign
click to edit