Registrar’s Office
Refund Appeal
I
mportant: Complete this form only if you are seeking an exception to the MCC Refund Policy. The Refund Appeal Form is intended to extend the refund period for a limited 10-day period for
students experiencing extraordinary circumstances. No refunds and appeals will be considered after the 10-day extension period. The full withdrawal and refund policy can be found at
www.manchestercc.edu/refund.
Appeals will only be considered for the following extraordinary circumstances: severe illness or medical emergency (a doctor’s note is required), military transfer (a copy of the
transfer orders is required) or administrative error (provide documentation to support your request). The following circumstances will NOT be considered: change of employment situation,
misunder-standing of start date or dates of class, misunderstanding of registration process, inability to transfer course, normal illness, transportation issues, childcare issues, poor decision or
change of mind by student regarding course selection, or dissatisfaction with course content or instructor.
Instructions for completing this form and submitting an appeal: Read the Refund Policy and determine if you meet the guidelines. If you meet the guidelines, you must withdraw from
course(s) prior to submitting an appeal. Appeals for fall, spring and extension courses (summer, winter and accelerated sessions and Continuing Education non-credit courses) must be submitted
within 10 calendar days from the start of the class. Provide all information requested below and attach supporting documentation. Forms without documentation will not be considered. Sign, date
and submit in person to the Registrar’s Office, SSC L157, or mail to Refund Appeals Committee, Registrar’s Office MS #13, Manchester Community College, P.O. Box 1046, Manchester, CT
06045-1046. The Refund Appeals Committee meets twice per month. You will receive a written response notifying you of the outcome.
STUDENT INFORMATION
First Name MI Last Name Banner ID Number
Mailing Address
City State Zip
Semester and year (please check only one):
n
Fall __________
n
Spring __________
n
Summer __________
n
Other ______________________________________
Phone Number Email Address
LIST COURSES AND REASON FOR REFUND EXEMPTION
CRN/Course CRN/Course
CRN/Course CRN/Course
CRN/Course CRN/Course
Reason (Please attach supporting documents; requests will not be considered without appropriate documentation.)
SIGNATURES
Are you a receiving financial aid? (please check only one):
n
Yes
n
No
If yes, you MUST obtain the signature of a Financial Aid staff member before submitting this form or appeal will not be
considered. Please consult financial aid staff as federal regulations may affect your account.
Financial Aid Staff Signature
Date
Student Signature
Date
Date: _____/______/_______ Adjustment: ___________________ Denied: ___________________ Response: ___________________
August 2018/PR
FOR OFFICE USE ONLY
