If an explanation, along with any supporting documentation is not included in your submission, your appeal will
be denied
ent Name: Student ID#
Contact Phone: (Day) Email Address:
g Address:
Complete mailing address including city, state, zip code
Financial Aid Applicant/Recipient Yes No CSM account paid in full Yes No
VA Educational Benefits Recipient Yes No FACTS Payment Plan Yes No
Employer Tuition Assistance Recipient Yes No
Year Course and Section Number:
: Year Course and Section Number:
: Year Course and Section Number:
: Year Course and Section Number:
Semester: Year Course and Section Number:
Class d
ate withdrawn (if applicable) Refund % received:
Method of registration: WEB In Person Campus: Date:
Method of withdrawal: WEB In Person Campus Date:
n requested:
Refund request Remove outstanding account balances Change of grade from an “F” to “WD
for requestDocumentation must be attached
Withdrawal due to student medical reasons (Documentation needs to clearly show date of occurrence.)
Withdrawal due to military deployment (Military orders must be attached.)
Death - of an immediate family member (Obituary or death certificate must be attached showing relationship.)
Other Extreme Situation - (Provide letter of explanation in detail the nature of the request, list any specific
circumstances that may support the request, and provide available documentation.
Feel f
ree to attach an explanation (typed) as to why you are making an appeal NO MORE THAN ONE PAGE.
nt Signature: Date:
College of Southern Maryland - Attn: Student Appeals REG P.O. Box 910, La Plata, MD 20646
Please make a copy for your records before forwarding. Allow six-eight weeks from the time of submission for a response.
Revised: 07/19/19
Student Appeal for an exception to CSM withdrawal and/or refund
An involuntary withdrawal, partial refund or credit of tuition and course fees after the normal refund deadline may be given if
the student submits a written request and appropriate substantiating documentation to support such a withdrawal request prior
to the end of the course. The policy can be found at: https://www.csmd.edu/about/policies/involuntary-withdrawal-policy/
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