Revised 12/20/18
Approved______ Denied______
Request to Waive Fees
$75 Late Payment Fee
________________ __________________ __________________ _______________________
Last Name First Middle Student ID Number
_
__
____________________________________________________ _______________________
Current Address Phone Number
______________________________________________________ _______________________
Email Address Effective Semester/Year
This form is to be completed by a student who is asking for waiver of the fee for a particular semester. Such requests are reviewed and acted upon by
the Vice Chancellor of Finance & Business Administration (CFO).
The decision is not final until processed through the Accounting Office. Waiver request approvals are extremely rare and require extenuating
circumstances.
_____________________________________________ ____________________
Student’s Signature Date Initiated
Attachments: Student must provide:
_____ Student Statement (explain why a waiver of the fee is being requested)
_____ Student’s External Documentation of claim (accident reports, insurance claims, hospital records, emails etc)
If complete documentation is not attached request will not be considered.
Do Not Write Below This Line
_____ Student Transcript showing semester in question
_____ Student Fee Bill/Balance owed from semester in question
________________________________________________________________________________________________
CFO Signature: ___________________________ Date:_______________ Approved___ Denied______
Comments:______________________________________________________________________________________
_______________________________________________________________________________________________
For Office Use Only
Accounting Staff: ________________________________________ Date:__________________
Keyed into computer by
__________ Student notified of decision (e-mail or letter)
