Riverside Community College District
COTOP APPEAL
This form is for students who received a letter from the RCCD Controller regarding outstanding fees and wish to file an
appeal due to documented extenuating circumstances. Students are required to drop themselves from classes if they choose to
not attend. Extenuating circumstances are verified, documented cases of accidents, illnesses, or other circumstances beyond
the control of the student. No appeal will be considered without proper documentation.
Student:
Name:_________________________________________ Student ID #:_____________________
Last First M.I.
Address:_______________________________________________________________________________
Street City State Zip
Email:___________________________ Phone:_______________________________
Please list the specific course/s and semester/s in your request:
Semester:_________
____________ Semester:__________________ Semester:_________________
College:______________________ College:___________________ College: _________________
Course:_______________________ Course: ___________________ Course: _________________
Section #:_____________________ Section #:__________________ Section#:_________________
Reason you are subm
itting petition, check all that apply:
□ Remove fees □ Remove W’s □Remove/Change Grade □Other (brief explanation)_________________
Clearly state your request and explain the extenuating circumstances in as much detail as possible.
If necessary
please use additional paper and include documentation. Allow at least 3 weeks for processing. Your response will
be mailed to you.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Student’s Signature:__________________________________ Date:_________________________
INSTRUCTOR/DEPARTMENT CHAIR/DEAN OF INSTRUCTION RECOMMENDATION USE ONLY:
□Recommend Approval □Recommend Disapproval Comments________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________
____________________________________________________________________________________________________________
Instructor/Department Chair/Dean of Instruction Signature:__________________________________ Date______________
ADMISSIONS & RECORDS OFFICE USE ONLY
□Approved □Disapproved
Comments:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Dean/Director Signature:________________________________________________ Date______________
KMOC 9/19
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