Student ID Last Name First Name Phone
Student Email Address:
Class Number Subject/Catalog # (ENGL 110) Instructor Credit Hours Date Student Withdrew
Student Signature Date
For Student Accounting Office Use Only: Return Form and Documentation to:
Approved: _______ Denied: _________
Letter of Credit (LOC): $ __________
In some extenuating circumstances, a student may be eligible for a tuition credit or balance adjustment. State your
situation below and attach supporting documentation
related to your personal situation that prevented you from
attending class. Some examples of supporting documentation include medical records, an obituary, or a letter from
your employer indicating a significant change in your work schedule.
If this appeal is related to the COVID-19 pandemic, please give specific examples of how the COVID-19
directives have impacted your ability to continue in your classes.
Supporting documentation is required - without it - the appeal will not be reviewed.
I certify the above information is true and correct. I understand the decision is final and I will be notified via email when a
determination is made.
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