Fillable SPECIAL FEES PAYMENT FORM (California State University, Dominguez Hills)

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SPECIAL FEES PAYMENT FORM (California State University, Dominguez Hills)

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SPECIAL FEES PAYMENT FORM
Cashier’s Oce Validation
Name: Date of Request:
Print Last First Middle
Address: Student ID/Soc. Sec. #
City StateNumber/Street Zip
Special Fees as approved by Title V; the Education Code, SUAM, and the Memoranda of Instruction including Executive Order #661.
INSTRUCTIONS: Obtain form from the appropriate Unit Oce or the University Information Center. Complete entirely, indicating the
services being requested. Return the form in person to the Cashier’s Oce and pay the appropriate total fee(s) amount. is form, aer
being validated by the Cashier’s Oce, is returned to the oce from which the service is requested.
Oce of Admissions and Records
ACCT#
Code #1LAP
Acct #1-19953
Code #1DPR
Acct #1-19827
Code #1DPR
Acct #1-19827
Code #1DPR
Acct #1-19827
Code #1DPR
Acct #1-19827
Code #1DPR
Acct #1-19287
Code #1DPR
Acct #1-19827
Code #1DPR
Acct #1-19827
Code #1IDF
Acct #7-51104
ACCT#
Code #1FPR
Acct #7-58120
Code #1POR
Acct #7-58120
Department of Public Safety
FEE
Late Application Petition .................................................................................
AMOUNT
$15.00
$4.00
$5.00
$10.00
$10.00
$10.00
$10.00
$5.00
$10.00
Duplicate Document $2.00/page; $4.00 minimum .........................................
Enrollment/Degree Certication ....................................................................
Revised Evaluation ...........................................................................................
Emergency Transcript .....................................................................................
University Policy Petition for Exception .........................................................
Missed Deadline Petition ................................................................................
Emergency Grad Clearance .............................................................................
Student ID Card Replacement .........................................................................
Fingerprinting ..................................................................................................
Police Reporting $2.00/page; $4.00 minimum ...............................................
FEE AMOUNT
Revised: March 23, 2020
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SPECIAL FEES PAYMENT FORM (California State University, Dominguez Hills)

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Completed 18 August 2020

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