TITLE IV AUTHORIZATION FORM
OFFICE OF FINANCIAL AID & SCHOLARSHIPS 2601 GENTILLY BLVD. ROSENWALD ROOM 126 NEW ORLEANS, LA 70122 PHONE: 1-504-816-4677 FAX: (504) 816-5456
(1) PRIOR TERM CHARGES AUTHORIZATION:
Federal Title IV financial aid funds are restricted to payment of current period tuition, fees, room and
board. Students may authorize use of these funds for prior period expenses, not exceeding $200. To
enable Dillard University to use your Title IV financial aids funds in this manner, please indicate your
choice below.
___ I authorize Dillard University to use Federal Funds/aid for prior year charges.
___ I do not authorize Dillard University to use Federal Funds/aid for prior year charges.
(2) NON-INSTITUTIONAL CHARGES AUTHORIZATION:
Program regulations permit students to authorize use of Title IV financial aid funds for non-institutional
charges such as books, and miscellaneous fines (e.g. parking and library fines). If you are eligible for
Federal financial aid in excess of tuition and fees, and you wish to use this excess to cover other charges,
you must authorize Dillard University to pay these charges.
___ I authorize Dillard University to apply the credit balance derived from Federal funds/aid to charges to my
student account for other non-institutional charges.
___ I do not authorize Dillard University to use the credit balance derived from Federal Funds/aid to charges to
my student account for other non-institutional charges.
(3) CREDIT BALANCE AUTHORIZATION:
Once Federal Title IV financial aid funds are disbursed to your student account to be applied to tuition,
fees, room and board, those funds may exceed those charges. Students may choose to leave those funds
on their student account for future charges. Please indicate your choice below.
___ I authorize the Business & Finance Office to apply any credit balance that may result on my student
account from application of Federal aid to be applied to future charges. I understand that I will not be given a
refund for this amount, and that the credit will be applied toward future charges including those, which may
arise from next semester’s tuition and fees. I also understand that I may make a written request that this
authorization be revoked at any time.
___ Please refund any credit balance remaining on my account after current semester charges have been applied
against available funds.
I understand this is a voluntary authorization and is valid from the date of signing through the date of graduation.
At any time I can cancel it in the Office of Business & Finance or in the Office of Financial Aid. I further
understand that I will be responsible for paying any outstanding debts if I cancel this authorization.
A financial hold will be placed on a student’s account for any outstanding balance that will prevent future course
registration/drops or transcript releases until the account is paid in full.
Student Signature_________________________________ Student ID#______________________
Name (Printed)___________________________________ Date ___________________________
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