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: _____________
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ACCEPTABLE REASONS FOR AN EXCUSED WITHDRAW
In accordance with Title 5, section 55024(e), an EW is acceptable when a student withdraws from a course(s) due to
reasons beyond their control, which include but are not limited to, the following:
Job transfer outside the geographical region;
Illness in the family where the student is the primary caregiver;
An incarcerated student in a California State Prison or County Jail is released from custody or
involuntarily transferred before the end of the term (In the case of an incarcerated student, an
excused withdrawal cannot be applied if the failure to complete the course(s) was the result of a
student's behavioral violation or if the student requested and was granted a mid-semester transfer);
The student is the subject of an immigration action;
Death of an immediate family member;
Chronic or acute illness;
Verifiable accidents; or
Natural disasters directly affecting the student.
Verifiable documentation can include, but is not limited to a note from a doctor stating the student is not currently
able to complete the work due to illness, employment verification of a new job, a booking report, police report of an
accident, or any other documentation that proves the student’s completion of a course is impractical. The
Chancellor’s Office defines impractical as impossible due to reasons beyond the student’s control. The determination
shall be made by the local college’s admissions and records office.
A student may request to use an EW for only one course or all courses in a term depending on the reason for the
request. It is possible a student, based on an illness for example, is not able to participate in an in-person course but
is able to continue with online courses. Colleges should use individual case facts to determine the continuity of some
courses and not others.
ADDITIONAL STIPULATIONS
In accordance to Title 5, section 55024 (e), an EW symbol may be requested by the student at any time during the
semester and no later than the date when the district/college policy allows a grade change. Excused Withdraw shall
not be counted in progress probation or dismissal calculations nor shall it be counted towards the permitted number
of withdrawals or counted as an enrollment attempt. The financial aid of a student may be affected depending on
individual circumstance. A student should consult with the financial aid staff regarding any impact.
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