Tuition Appeal Form
Complete and submit this form to the Tuition Appeals Committee, Lehigh Carbon Community College, 4525 Education Park Drive,
Schnecksville, PA 18078, or fax to 610-799-1641. This form may also be dropped off at the Business Office or emailed to
bursar1@mymail.lccc.edu.
Be sure to include appropriate documentation (see below).
Falsifying information on this appeal will result in immediate denial and may be grounds for sanctions as outlined under the
Student Code of Conduct.
Name Student ID #
Address City State Zip
Phone Number Email Address
Semester appealing for: Spring Summer Fall Year ______ Receiving Financial Aid: Yes No
Specify Request: Tuition Refund Balance Waiver Debt Relief Program (account in collections)
Check Reason for Appeal
Student Illness: A note from your physician or medical provider on their letterhead indicating the dates you were unable to attend class.
The note must be signed by your physician or medical provider. Excuse slips, copies of invoices, appointment confirmations, statements of
insurance payments, etc. are not acceptable documentation. Do NOT send copies of your medical records.
Illness of Immediate Family Member: A note from your family member’s physician or medical provider on their letterhead indicating
the dates of illness and the need of a caregiver. The note must be signed by the physician or medical provider. Excuse slips, copies of
invoices, appointment confirmations, statements of insurance payments, etc. are not acceptable documentation.
Death of Immediate Family Member: Submit a death certificate, obituary or death notice. Documents must clearly indicate the
relationship of the deceased to the student. (Immediate family is defined as: parent, grandparent, sibling, child, spouse)
Military Deployment: A copy of the official deployment/reactivation notice. Deployment and reactivation dates must be within the
semester you are appealing.
Change in Employment beyond the student’s control that prevents the student from attending the classes for which he/she is registered.
A letter from your employer on company letterhead indicating the reason and date of the change in work schedule.
Verifiable Error of LCCC: Provide a detailed account of the problem and relevant documents on College letterhead from the College
Office involved or advisor indicating that incorrect information was given by a College representative.
Other: Provide a detailed account of the extenuating circumstance and submit copies of supporting documentation.
Attach a letter of explanation clearly explaining your situation and the reasons why you feel the tuition should be waived or
refunded. Include the reason you were unable to follow the usual refund/drop procedures. Please be as complete as possible.
Also, attach COPIES of the appropriate documentation needed to support the reason you checked above. The responsibility for
ensuring that LCCC has received the needed documentation rests with the student filing this appeal.
By signing this appeal, I acknowledge that I am responsible for withdrawing from my class(es).
Attached is a letter of explanation and the supporting documentation. Student letter must accompany this form for
consideration.
I understand the Tuition Appeals Committee will notify me in writing of their decision regarding my appeal.
I have spoken to a financial aid representative regarding the impact this appeal may have on my financial aid.
I have reviewed the information contained in this document and BY SIGNING BELOW, I UNDERSTAND THE IMPLICATIONS OF
MY APPEAL.
Type your full name in the Signature box. By typing your name in the Signature box, you certify that you are signing the
completed application.
Student Signature Date
DO NOT WRITE BELOW THIS LINE
Committee Actions
Approved
Notes:
Pending Additional Documentation
Denied
____________________________________________________ __________________________________________________
Committee Member Signature Committee Chair Signature
Date_______________________________________
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