Fillable Third-Party Agreement (TPA) Application (Portland State University)

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Third-Party Agreement (TPA) Application (Portland State University)

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Third-Party Agreement (TPA) Application
Instructions and Terms for Academic Year 2019-2020
A Third Party is an entity that has agreed to pay all or a specified portion of a student’s or group of
students’ tuition, fees and other charges at an institution of higher education. Portland State University
will invoice sponsors that require a separate invoice for the items on the student bill which the sponsor
will pay in support of a student. To be considered for the TPA billing process, sponsors must complete
this application form for the 2019-2020 academic year and return to the Student Financial Services
Office. Note: There is a $25 TPA service charge per student per term.
Unless otherwise noted, a completed application form and a letter of support are due by the following
dates in order to ensure coverage for the associated term(s):

Term
Application Due Date
Fall
2019
October 1st, 2019
Winter 2020
January 7th, 2020
Spring 2020
March 4th, 2020
Summer 2020
July 1st, 2020
Sponsor’s Billing and Contact Information
Organization Name: ______________________________________________________________
Billing Address: __________________________________________________________________
City, State, Postal Code, Country: ____________________________________________________
Billing Contact Name: ____________________________________________________________
Billing Contact Title: ______________________________________________________________
Billing Contact’s phone #, with international codes: _____________________________________
Billing Contact’s fax #, with international codes: ________________________________________
Billing Contact’s email: ____________________________________________________________
Name of person authorized to submit this agreement: __________________________________
Student Financial
Services | Post Office Box 202, Portland OR 97207-0202
studentfinancialservices@pdx.edu | T: 503-725-3440 F: 503-725-5458
Payment is due 60 days after the invoice date.
Payment Methods
Third-Party Agreement (TPA) invoicing payments can be made by check, credit card, cashier’s check,
money order or wire transfer drawn on U.S. funds. To ensure proper credit, provide the TPA Invoice
number and the students’ Portland State University ID number with the paymen t. Please make
checks payable to Portland State University.
Payment Address:
PSU Cashier's Office
PO Box 908
Portland OR 97207
Electronic funds transfer:
To set-up wiring information: Please contact Amy Bowen, 3
rd
Party Billing Financial Coach, at
503-725-9668 or 3rdparty@pdx.edu. Please note that banks will charge you a service fee of
approximately $10.00-to $60.00 to initiate the wire transfer. Wire fees are in addition to the invoiced
amount due to Portland State University.
TPA Invoicing FERPA Disclosure
Portland State University is prohibited by the federal Family Educational Rights and Privacy Act (FERPA)
from releasing class names, descriptions, transcripts, grades, financial aid information, or information
about other charges. The student is responsible for providing this information to the sponsoring
organization if it is required. The student must authorize the Student Financial Services Office to release
necessary information to his/her sponsor for the purposes of Third-Party Agreement quarterly
invoicing. This may include electronic transmission methods (email, fax, etc.), if requested.
Sponsor Agreement
The TPA credit will be applied to the student's account prior to invoicing the sponsor. It is understood the
agreed upon charges are not dependent on attendance, obtaining a grade, performance and/or financial
aid status. If the sponsor does not pay the TPA invoice within 60 days of the issuance of the invoice,
Portland State University reserves the right to remove the TPA credit applied to the student’s account.
These charges will then be due and payable by the student. This action may cause the student’s account to
become past due and delinquent. The student’s account may be placed on hold. This hold will prohibit
future enrollment, transcript and diploma releases. The student will have 30 days to pay the balance in
full. If this account is referred to an outside collection agency, the student may be responsible for all
collection costs, interest, legal and court fees, if applicable.
Student Financial Services | Post Office Box 202, Portland OR 97207-0202
studentfinancialservices@pdx.edu | T: 503-725-3440 F: 503-725-5458
Student Information
Complete this application for a single student. For a group of students, provide a roster, which must
include the following information for each student sponsored by the organization.
Last Name: ___________________________________________ MI: ________________
First Name: ___________________________________________ DOB: _______________
Portland State University Student ID#: _______________________________________________
Sponsor Reference # (if applicable): __________________________________________________
Program (if applicable): ___________________________________________________________
Maximum credit hours per term (if applicable): ________________________________________
Indicate the terms that your organization will sponsor this student for the 2019-2020 year
Fall 2019
Winter 2020 Spring 2020
Summer 2020
Please indicate charges covered by this TPA. All other charges will remain the student's’ responsibility and
will be subject to the Portland State University Payment Plan.



Charges to be invoiced: Maximum Amount (If applicable):
❏ Tuition
❏ Mandatory Fees
❏ Class Fees
❏ Online Learning Fees
❏ Health Insurance
❏ Housing Charges
❏ Meal Plan
❏ Matriculation Fee
❏ TPA Service Charge ($25)
❏ Other (please specify)
Any additional information/requests (i.e. grades, class schedules, additional funding):
_____________________________________________________________________________________
Student Financial Services | Post Office Box 202, Portland OR 97207-0202
studentfinancialservices@pdx.edu | T: 503-725-3440 F: 503-725-5458
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Third-Party Agreement (TPA) Application (Portland State University)

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Completed 26 August 2020

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