I, ___________________________________, for value received, promise to pay Luna
Community College, the sum(s) indicated below, the authenticity of which is/are
acknowledged by my signature below, due and payable and which is acknowledged by
the LCC Fiscal Office. The amount below reflects Tuition and Fee charges and will
change if bookstore charges are incurred or my schedule changes
I hereby authorize Luna Community College to credit my College Work Study, Pell Grant, SEOG and/or any other
financial assistance awarded into my account and/or to withhold from my pay any balance remaining on my account.
I further agree to pay all costs of collection, including reasonable attorney fees, in the event that this note or any part
thereof is not paid as herein required. I further understand that if I default in payment on this note, LCC may seek
collection of the same through a collection agent, referral to a credit reporting bureau, or suit, in which event I
understand that a judgment against me may be satisfied through garnishment of my wages or in any other manner
provided by law.
I further understand that I may not be able to register for subsequent semesters nor obtain a transcript if a balance
remains on my account. Failure to uphold this agreement may disqualify me from executing a future promissory note.
Fees and Tuition subject to change.
LCC does NOT bill on a monthly basis and it is the responsibility of the student to make payments as agreed.
Signature of student Date
Phone # __________________ Last four # of SS______________
Name, address and phone number of nearest relative not living with you:
Sum Due and Owing Semester
Balance to be paid in full by the end of the current semester. ______________________
rev.08-08 Fiscal Office Approval/Date