Revised 4/8/2020
2830 Napoleon Rd ● Fremont OH 43420
419.559.2329 or toll free 866.AT.TERRA ext 2329
Student Appeal Petition for Medical / Compassionate Withdrawal
and / or Review of Billing Charges
The Student Appeal Petition for a Medical / Compassionate Withdrawal and / or Review of the Billing Charges
allows students to petition for a hardship course withdrawal and / or an adjustment of their charges. The
Associate Dean of Students will review all student requests individually and make a determination based on
Federal, State, and Institutional policies. Students submitting an appeal will need to meet all requirements and
stipulations stated below before the petition will be reviewed. The Associate Dean of Students will review
petitions and notify students in writing by Terra State e-mail (Office 365) of the findings.
*Entire form must be completed in order to be reviewed.
*Documentation associated with appeal must be attached
& clearly identify the unusual or extenuating circumstance.
*Charges must still reside at Terra State & not have been
transferred to the OH Attorney General’s Office (OAG).
*One appeal per issue.
*Un-Appealable issues include, but are not limited to:
Grade change requests, missing the 100% drop date,
Academic Probation or Suspension, Return of Title IV
Funds, & charges that reside with the OH Attorney
General’s Office (OAG).
Student Name:____________________________________________Student ID: T00__________________
Please Print Legibly
Address: ________________________________
Include street, apartment, city, state, zip
Terra E-Mail:_________________ Telephone:(___ )___________________
Term requesting appeal: ___ Fall ___ Spring ___Summer Year: 20______
I have dropped my classes in BANNER: yes no
If not, log into your BANNER Self-Service to drop classes, if possible: yes no
Examples of Acceptable Documentation to Support Petition
Medical Condition of Self or Immediate
Family Member
Signed & Dated statement from physician (on letterhead)
Medical documents
Death of Immediate Family Member
Obituary or Death Certificate indicating relationship to student
Documentation of extenuating circumstances preventing attendance
and / or impeding successful academic performance
Caregiver Obligations
For relationship other than dependent, signed physician statement of
relationship and obligation of caregiver
Signed statement or document written on letterhead from third-party
indicating relationship and obligation of caregiver (i.e. hospital, school,
company, etc)
Change in Employer Requirements
Signed & Dated statement from employer / supervisor on company
College Error
Signed & Dated statement from college official indicating error written
on letterhead
I will be attaching a typed personal statement to support my appeal (optional): Yes No
Potential topics to include: specification of the outcome(s) you desire from the appeal; your goals & approach for being
successful in future semesters; what circumstances led up to the event indicated; etc.
Revised 4/8/2020
Please read the following and initial each statement indicating that you understand:
____ I understand and certify to the best of my knowledge, that I meet all eligibility requirements listed above.
____ I understand that the appeal petition will not be considered complete until all portions are completed and all applicable
documentation is submitted.
____ I understand that submitting an appeal is not a guarantee of approval; consideration is based on Federal, State, and
Institutional policies.
____ I certify that I reviewed the 100% Drop Date(s) and am now facing financial consequences if this appeal is denied.
____ I understand that my appeal is reviewed on a case by case basis and I will be notified by Terra State e-mail (Office
365) whether the petition was approved or denied. If approved, the Terra State e-mail message will also indicate
any additional steps or terms of the appeal decision that I must abide by.
____ My last date of attendance was___________________ , TSCC is authorized to withdraw me as of this date.
____ I understand that I am not present during the Appeal Petition review process; therefore, the documentation and
explanation of extenuating circumstances submitted by me is used to make the final Appeal Petition decision.
Student Signature: ________________________________________________ Date: ________________________
Associate Dean of Students:
Terra State Office use only
Financial Aid Office:
Cashier Office
Records Office:
Financial Aid Office:
R2T4 completed
Cashier Office:
Final Decision of Vice President of Student and Enrollment Services: if applicable
Records Office:
Final Processing
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