Finance Charge Appeal Form
Student's Name Student ID
Date Student Email
I am requesting to have the finance charge listed below removed from my student account:
Student Accounts
800 West College Avenue · St. Peter, MN 56082-1498 · www.gustavus.edu
Sara Orth, Director · Amy Braun, Assistant to Director
Telephone: (507) 933-7502/6244 · Fax: (507) 933-7727· E-mail: studentaccts@gustavus.edu
FOR STUDENT ACCOUNT OFFICE USE ONLY
Approved Denied
Date student was emailed the decision______________(attach copy of email for student file)
If approved: 1. Amount of finance charge removed $____________
2. Date adjustment completed___________
Office staff initials____________
Signature of Student
Reason for
appeal
Month Finance Charge Amount
I understand that Gustavus Adolphus College expects that I arrange for my student account to be paid by the due
date listed on each monthly statement that is sent to me. This includes any financial aid or alternative loans that
I can apply for to help pay the balance due. Otherwise the College reserves the right to assess a monthly finance
charge of 1% to my unpaid balance.
We will notify you of our decision via email within two (2) weeks of receipt of this form.
