Exception to Withdrawal or
Refund Appeal
Name: Student ID#:
In keeping with Florida Administrative Rule 6A-14.0541, The College of the Florida Keys will
consider a petition for withdrawal or refund when the student files a request claiming that the
student was unable to complete the semester due to circumstances determined by the college to
be exceptional and beyond the control of the student. Such circumstances include, but are not
limited to:
serious illness;
documented medical condition preventing completion;
death of an immediate family member (father, mother, sister, brother);
involuntary call to active military duty;
documented change in conditions of employment;
The following circumstances are NOT considered extraordinary and extenuating, and are NOT
eligible circumstances to file for an exception:
Transportation issues;
Issues involving course content;
Issues involving method of instruction; and/or
Issues involving a lack of understanding of the withdrawal/refund policy as printed in
the college catalog & student handbook.
To petition for an exception to the College’s Withdrawal or Refund policy, complete this
form and submit the following required documentation in support of your request:
A Letter of Explanation: please describe your major extenuating circumstance(s) that
is the reason for your request;
Copy of student bill and schedule;
Letter from the instructor(s) of the course(s) you are requesting the exception for
verifying your attendance and current grade; and
Relevant documentation: (Please select applicable documentation(s) you are
Medical-Physician’s letter on official letterhead, or other medical documents,
indicating the severity, duration, and academic impact of the condition and
recovery period.
Employment-A letter from your employer, on company letterhead, indicating that
your employer changed your work schedule and that this change prevented
75.59(D) Revised 9/20/2019
Name: Student ID#:
you from completing the term. The letter must include old and new work hours
and the effective dates.
Death (Immediate Family Member or Guardian)-Documentation of death must
include one of the following; an original death certificate, newspaper notification,
or obituary. It is your responsibility to establish your relationship to the deceased
Active Military Duty- Documentation must include a copy of orders.
College Change or Error-A letter from the appropriate college official
documenting the situation in which the College was in error or initiated an action
that caused you to withdraw from your course(s).
Campus: Key West Marathon Coral Shores/ Upper Keys Virtual
Term request is for: Academic year:
Type of request: Request for withdrawal, no refund Request for withdrawal, with refund
Complete the information below for the course(s) that you are requesting an exception due
to extenuating circumstances:
Course Title Course Course # CRN (5
Prefix digits)
Deadline: NO REQUEST will be considered AFTER 120 days of when final grades were
posted for that semester according to the Academic Calendar.
I understand that:
Requests received without proper documentation will be returned and not reviewed until
proper documentation is provided to the Committee and this could jeopardize the
timeliness of the Committee’s decision.
It is my responsibility to monitor my CFK email account for any correspondence from
the Committee regarding this request.
The Committee has the right to seek relevant input regarding this request from other
college departments, including instructors, and use this information in their decision-
It is my responsibility to withdraw from courses I no longer plan to attend and submitting
this Refund Request Form does not officially withdraw me from these courses or the
75.59(D) Revised 9/20/2019
If I am receiving financial aid, military assistance, veterans’ benefits, or am an
international student, it is my responsibility to check with the appropriate office to
determine if this request will affect my benefits or status.
I authorize any refund of cash payments to be applied to prior debt before release to me.
If my account has been turned over to collections, I may be obligated to repay the
collections fees to the collections agency even if a refund is granted. If I received
financial aid, my refund will first be applied towards any return required to the federal
government or to reduce any current semester loans. If I received an institutional
scholarship that paid for tuition, any refund will be returned to the school fund.
I accept the decision of the Student Services Appeals Committee as final and not
subject to further appeal within the college.
By signing below, I certify that I have read and understand all of the information on this form. I
further certify that all statements and documentation provided by me in support of this exception
are truthful and representative of the facts concerning the extenuating circumstance(s).
Students signature: Date:
Submit your request for consideration to:
CFK Student Services Appeals Committee
The College of the Florida Keys, 5901 College Road, Key
Phone: (305)809-3292 Fax: (305)292-5163
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