Fillable INTERNAL BILLING AUTHORIZATION (University of Minnesota - Crookston)

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INTERNAL BILLING AUTHORIZATION (University of Minnesota - Crookston)

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INTERNAL BILLING AUTHORIZATION
RETURN FORM TO:
Third Party Billing
University of Minnesota, Twin Cities
169 Fraser Hall
106 Pleasant Street SE
Minneapolis, MN 55455
Phone: 612-625-8559
Fax: 612-626-0387
Email: tpbill@umn.edu
DIRECTIONS—Use this form to set up internal billing authorizations on
student accounts. Authorizations must be submitted before the due date of the
rst student bill. Please go to onestop.umn.edu/onestop/Tuition_Billing/wwhpay.
html for applicable payment due dates. Late payment fees and installment/re-
billing fees that result from submitting authorizations after the rst student due
date will not be waived. If you want to provide authorization for more than one
student, you may attach a list with the names, student ID numbers, and maxi-
mum dollar amounts for any students not listed in Section B.
Go to z.umn.edu/fmv for tuition and fee rates.
To request copies of this form in an alternative format, please call the Disability Resource Center liaison
at 612-625-9578. The University of Minnesota is an equal opportunity employer and
educator.
*FA864*
fa864 8/14
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SECTION A. Department information
Department name College
Contact name Phone number Contact person’s email
Charteld string
SECTION B. Student information
Name (last, rst, middle initial) University ID
Authorized terms (check all that apply):
fall term 20___ spring term 20___ May/summer term 20___
If the award is authorized for multiple years:
fall term spring term 20___ to: fall term spring term 20___
SECTION C. Authorized coverage
Check the internal billing category that corresponds to the charges you want to set up for internal billing.
If applicable, enter the maximum dollar amounts that the department will pay for each specic charge.
Internal billing categories Maximum $ amount
Collegiate fees
$
Course fees
$
Late payment and installment plan/re-billing fees
$
Late registration fees
$
Optional fees
$
Required fees
$
Health insurance
$
Tuition
$
Other (please specify)
$
Additional information:
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Completed 24 July 2020

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