Student ID/SSN:
Street Address:
Home Phone:
Work Phone:
Fee(s) requested to be refunded:
For tuition and registration charges, please complete below:
Class(es) Dropped
Date Dropped
Method of Payment used:
Original Receipt #:
Describe in detail the reason you are asking for an exception to the policy. Please note that exceptions
are typically made only for (1) incapacitating personal injury or illness; (2) death of an immediate
family member (mother, father, sister, brother, child, spouse); (3) error made by Washington State
Community College; or (4) natural disasters (fire, flood, etc.).
Please see reverse side for further explanation and mandatory criteria.
Request for refund approved by:
Academic Advisor/Dean
Financial Aid Director
Registrar, Records Office
Controller, Business Office
All requests
must be accompanied by acceptable documentation of the situation as follows and must
be made prior to the completion of the next academic term:
Personal injury or illness Letter from physician stating your diagnosis, the dates of your illness or
hospitalization, and a recommendation that you discontinue your classes.
Death in immediate family Obituary that lists your name and relationship to the deceased.
Error made by Washington State Community College Letter from the office involved in the error.
Natural disaster Police report, fire department report, or insurance document.
The decision will be mailed to you within three (3) days of the receipt of your completed form and
documentation. All decisions are final.
Submit this form to the Controller in the Business Office upon obtaining signatures from all other
relevant parties, 710 Colegate Drive, Marietta, Ohio 45750.
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