Lorain County Community College Financial Services 1005 N. Abbe Rd, Elyria, OH 44035 Fax: 440-366-4634 Page 1 of 1
Request for Administrative Withdrawal Form
2020-21 Financial Aid Year
Only complete this form if you are currently registered for the indicated semester and wish to be withdrawn.
Section 1. Student Information
Last Name First Name Middle Initial
LCCC Student ID #
I request that I be totally (100%) withdrawn from the following semester and not owe any tuition and fee charges for the semester. I
understand that I am responsible for any purchases made at the bookstore.
Indicate the semester:
Summer 2020 (Submission deadline: Friday, June 5, 2020)
Fall 2020 (Submission deadline: Friday, September 4, 2020)
Spring 2021 (Submission deadline: Friday, January 29, 2021)
Section 2. Certification.
I certify that all of the information reported is complete and accurate. Warning: If you purposely give false or misleading information on
this worksheet, you may be fined, sentenced to jail, or both.
Student Signature: Date
Electronic signatures will not be accepted. Please print this form to sign before submitting.
Section 3. Submission
You may submit your information by: a) mail to the address below; b) fax to 440-366-4634 or; c) deliver to Financial Services, First Floor, Bass Library. Do not email
any documents with personally identifiable information.
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