Page | 1 SAC | A&R | Rev. 2/25/19
Office of Admissions & Records
1530 West 17
th
Street, Santa Ana, CA 92706 |www.sac.edu
phone: (714) 564-6005 | email: Adm_Records@sac.edu
Petition for Excused Withdrawal OR Military Withdrawal
IMPORTANT: This petition must be filed no later than one year following the awarding of the original grade. The petition MUST include all
required documents and/or signatures. An incomplete petition will not be accepted.
Student Name: _____________________________________________________ Student ID#: _______________________
(Last) (First)
Phone: _________________________________ E-Mail: ______________________________________________________
I understand that by submitting this form, I am NOT guaranteed an exception to the withdrawal deadlines.
I confirm that all of the information I have presented below is true and accurate.
I understand that this decision is final.
Student Signature: ______________________________________________________ Date: ________________________
Are you a Financial Aid recipient?:
Yes (see below)
No
As a financial aid recipient, I understand that if this request is granted it may impact the financial aid received for this term and/or any future
term if the standards of academic progress are not met. By making this selection, I assume all responsibility for adverse consequences.
This petition applies to the following term: Fall 20_____ Intersession 20_____ Spring 20_____ Summer 20_____
Select which of the following circumstances apply to you (check one):
Excused Withdrawal: A student may petition for an Excused Withdrawal due to extenuating circumstances, which occurred after census.
Extenuating circumstances are approved based upon verifiable documentation supporting the request (see back page for more details). If
approved, the petitioned classes will be designated with an “EW (Excused Withdrawal) on the transcript. An “EW” will not be counted in
progress probation or dismissal calculations nor will it be counted towards the permitted number of withdrawals or counted as an
enrollment attempt. (REQUIRED: Personal statement providing a justification for the petition and verifying documentation for the
extenuating circumstances submitted along with this petition)
Please list the classes for which you are petitioning an Excused Withdrawal (EW) below.
Course Subject/Number
(e.g. ENGL-101)
Section Number
(e.g. 54321)
Military Withdrawal: A student who is a member of an active or reserve U.S. military service and has received orders compelling a withdrawal
from courses may request a military withdrawal. If approved an “MW” will appear on the transcript for each course. “MW” shall not be counted
in the permitted number of withdrawals nor shall it be counted in progress and dismissal calculations. (REQUIRED: A copy of the student’s
military orders submitted along with this petition)
FOR OFFICE USE UPON RECEIPT
Student Signed & Dated
Personal Statement (if required)
Verifying Doc. (if required) Staff Initials: _________ Date: _____________
APPROVED
DENIED | Transcript Updated (if applicable) Rebill (if applicable)
Dean of A&R Signature:__________________________________________________________ Student notified: PHONE EMAIL IN-PERSON
Comments: _______________________________________________________________________________ Staff Initials: _________ Date: _____________
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
