Office of Records and Registration
640 Bay Road, Queensbury, NY 12804-1445
CALL: 518.743.2279 | FAX: 518.832.7601 | EMAIL: registrar@sunyacc.edu
Official Withdrawal Form
This form should be used only after the first liability period has ended for the semester or part-of-term until the last day of class.
Withdrawal forms cannot be accepted after the last day of class.
Students are required to have Instructor Signature as noted below after the auto-withdrawal date, 60% mark of the part-of-term through
the last day of class [not final exam period].
Semester: ❑ Summer ❑ Fall ❑ Winter ❑ Spring Year: _________ Date: ______________________
Student Name: __________________________________________________ Banner ID: _________________________________
Please mark all that apply: * ❑ I receive Financial Aid (PELL, TAP, Excelsior, Loans, etc.). ❑ I receive Military Benefits.
❑ I live in the Residence Hall. ❑ I am an EOP Student. ❑ I am an HPOG student. ❑ I am a student athlete.
❑ Other: __________________________________________________________________________________________________
*If you selected any of the above options and you are withdrawing from one or all of your courses, you are strongly encouraged and may
be referred to speak with a representative of the associated office prior to submitting this form to the Registrar’s Office as it may have
implications on your bill, aid, enrollment status, or eligibility to participate in one or more of the above mentioned programs.
Course Withdrawal(s) Requested:
❑ I wish to withdraw from all of my registered credits. I will be enrolled in 0 credit hours for the semester. ____ (Initial)
Subject and Course Number
Instructor Signature (after auto-w only)
Bill Adjustment/Liability Schedule: Students who officially withdraw from the College may be eligible for a bill adjustment. The
adjustment is determined by the date the student processes a Withdrawal form at the Registrar's Office, according to the schedule noted
below (some exceptions may apply). For more information, go to
http://catalog.sunyacc.edu/financialaid/billrefund.
Courses more than 8 weeks in length (W grade on transcript) Liability amount
Withdrawal before the end of the 2
nd
week of term 50% tuition/100% fees
Withdrawal before the end of the 3
rd
week of term 75% tuition/100% fees
Withdrawal after the end of the 3
rd
week of term 100% tuition/100% fees
Courses 3 to 7 weeks in length (W grade on transcript) Liability amount
Withdrawal through the end of the 1
st
week of term, Day 2-5 75% tuition/100% fees
Withdrawal after the end of the 1
st
week of term 100% tuition/100% fees
Courses less than 3 weeks in length (W grade on transcript) Liability amount
Withdrawal after the 1
st
day of term 100% tuition/100% fees
I understand by making the above requested schedule changes, there may be a change to my bill
(http://catalog.sunyacc.edu/financialaid/billrefund), Financial Aid, enrollment status, housing status, eligibility for military benefits and/or athletic
eligibility. The credits withdrawn above will count towards my attempted credits (unless they are remedial coursework credits) and will result in
a “W” or “AW” grade on my transcript. The withdrawal policy can be found at
http://catalog.sunyacc.edu/regulations/withdrawal.
Student Signature: ________________________________________ Date: _________________________ ❑ Administrative Change
❑ Picture ID attached if sent electronically
Student Success/Registrar Staff Only:
Student Success/Wilton Staff Signature: __________________________________________________ Date: ___________________________
❑ Reason for Administrative Change: ________________________________________________________________________________________
❑ Student has been referred to the Financial Aid Office ❑ Student has been referred to: _____________________________________
Financial Aid or other Staff Signature for Referrals: _________________________________________ Date: ___________________
For Registrar’s Office Use ONLY: Initials: ___________ Date processed: __________ Form Updated: 07/15/19
