If an explanation, along with any supporting documentation is not included in your submission, your appeal will
be denied
Stud
ent Name: Student ID#
Contact Phone: (Day) Email Address:
Mailin
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
Semester:
Year Course and Section Number:
Semester
: Year Course and Section Number:
Semester
: Year Course and Section Number:
Semester
: 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ate withdrawn (if applicable) Refund % received: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:
Actio
n requested:
Refund request Remove outstanding account balances Change of grade from an “F” to “WD”
Reason
for request – Documentation 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.
Stude
nt Signature: Date:
College of Southern Maryland - Attn: Student Appeals – REG P.O. Box 910, La Plata, MD 20646
appeals@csmd.edu
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
https://www.csmd.edu/about/policies/involuntary-withdrawal-policy/
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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