r. 4/2018
Special Withdrawal Petition
A special Withdrawal Petition is submitted at the last day to withdraw from the course. Y
our request
with only be considered if the circumstances were non-recurring, catastrophic, or life threatening in
nature, and beyond your control. The following are examples of acceptable events: medical, military
duty, jury duty, death of an immediate family member, family care, employment schedule changes or
college error. No more than 2 petitions in a 24 month period will be considered for a student.
Deadline: A Special Withdrawal Petition must be submitted by the last day of semester following the
semester in which the course(s) being petitioned.
Grades: If your request is approved, any grade change(s) will result in the issuance of a grade of “WD”.
Notification: You will be notified by email when a decision is made. Email will be sent to your Omail account.
Financial Aid Recipients – Approved requests could cause repayment of federal student aid received. If you are a financial aid
(FA) recipient, you are strongly encouraged to consult with an Oserve Advocate before completing this request.
OCID: ______________________________________________________________________________________
Printed Name: _______________________________________________________________________________
Phone Number: ______________________________________________________________________________
I have attached a signed statement containing my name, address, semester being petitioned, requested courses and an
outline of my extenuating circumstance including why consideration should be given to my request.
I have attached documentation supporting my extenuating circumstance. Examples include medical documentation from
a licensed professional submitted on letterhead, copy of orders for active duty, copy of obituary or death certificate, letter
from care facility on letterhead, signed letter from employer on company letterhead, documentation from instructor,
administrator or advisor for college error.
I am aware that I am responsible for any adjustments to financial aid, scholarships, loans, etc., that may be aected if my
request for special withdrawal is approved.
I have completed, signed and plan to submit this checklist, along with my signed typewritten statement and supporting
Will you be requesting an appeal of tuition/fees? YES NO
If yes, you will receive a form to complete only if your Special Withdrawal Petition is approved.
*Incomplete petitions missing checklist items with not be considered.
Please submit completed petitions to Oserve or by mailing or faxing to the Records Oce.
Statement of Acknowledgement: I hereby certify that the information provided is correct and true to the best of my knowledge.
I understand that submitting fraudulent information or failure to follow specified instructions may interfere with my request and
may subject me to federal and/or state penalties. I further understand that any misrepresentation of information may subject
me to administrative action in accordance to the Student Code of Conduct. I hereby authorize the Records Oce or appointed
representative reviewing my petition access to all documentation pertaining to my request.
Student Signature: _________________________________________________________ Date:__________________________________
Phone Number: ___________________________________________________________
Records Oce
P.O. Box 10,000
Toledo, OH 43699
Fax (567) 661-2101
Email: special_withdrawal@owens.edu
Oserve Oce
Phone (567) 661-7378
Toledo location: Student Service Center, College Hall
Findlay location: EC 112