Middlesex Community College Request for Delinquent Debt Repayment Form
Today’s Date: _______________
Student Information
Name:
Banner #: @
Street Address:
City/State/Zip:
Telephone:
The purpose of this form is to request special consideration for repayment of debt to MxCC to be authorized
by Dean Sykes. If approved by Dean Sykes, the hold will be removed from your account once your balance has been paid in full.
Please note that you cannot register for an upcoming semester until the debt is paid off.
Please explain the circumstance for this application in order to be considered for a Delinquent Debt Repayment Plan.
You must complete this section.
Please complete the proposed payment schedule with a reasonable request for a repayment plan. Installment plans are
available to defer tuition charges only
. Use the back of this page if necessary.
Proposed Payment Schedule
Total Tuition Owed: $______________.
Plus $25 Late Payment fee to participate in this plan: $_25.00_.
Grand Total: $__________________.
Payment Amount
(minimum $25)
Payment Due Date: mm/dd/yy
(max duration 2 years)
$
$
$
$
$
I understand there will be a $15 late payment fee applied to my account for each payment that is late. I agree to pay the
amounts specified above on the dates indicated. Any deviation from the schedule above must be approved by Dean Sykes.
Failure to adhere to the payment schedule will result in being administratively dropped from all classes with continued
obligation to the College for the total amount due.
I agree with the above criteria for this debt repayment plan and understand my obligations to the College.
_______________________________ ___________
Student Signature Date
Questions can be directed to: Jessie Cardona at
860.343.6906 or YCardona@mxcc.commnet.edu
Please remit to:
Jessie Cardona
Founders Hall Front Lobby, CICC
100 Training Hill Road
Middletown, CT 06457
Fax: 860.344.7488
For Office Use Only
X
Approval: Dean Sykes, Dean of Finance & Administration
Signature and Date
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