University Housing Services
Installment Deferment Request
Last Name: First Name: Sac State ID:
Hall/ Room #: A B C D E Phone #:
Please defer my following housing installments: (Mark Applicable Installment(s)
AUGUST SEPTEMBER OCTOBER NOVEMBER
JANUARY FEBRUARY MARCH APRIL
SUMMER SESSION #1 SUMMER SESSION #2
Please read and acknowledge the following statements:
I understand that this deferment will be based on Financial Aid funds that I have accepted but have not
yet been disbursed to my University account.
I understand that I am responsible for insuring that all Financial Aid documentation, loan counseling, etc.
must be completed as soon as possible for funds to be disbursed in timely fashion.
I understand that I am responsible for amount due on my account even if my financial aid award
changes or does not disburse.
I understand that I am responsible for any applicable late fees and or holds unless alternate payment
plan agreement is submitted and approved prior to due date.
I understand that if my request is denied, payment is due according to published payment schedule.
Student Signature: Date:
(For Office Use Only) Award Verification List awards for this term.
Award Type
Semester $
Total
Semester $
Already Paid
Semester $ Still
to Disburse
Checklist
Complete?
1 1 _ 1 1 1 _
2 2 _ 2 2 2 _
3 _ 3 _ 3 3 3 _
4 4 4 4 4 _
5 5 5 5 5 _
Term Balance Due:
Available FA For Housing Debt Total Still To Disburse:
Due for this Request: Less Tuition/Fees Due:
Determination: Approved
Denied:
Staff Initials
Date
Notes:
9/18
