Waiver & Refund Appeal Form
Important: Complete this form only if you are seeking an exception to the CCC Refund Policy. In the event a student experiences extraordinary
c
ircumstances that necessitates their withdrawing from a course beyond the allowable drop period, a refund & waiver appeal must be submitted within 10
calendar days from the date of withdrawal. For those students who do not withdraw and receive a grade, request must be submitted within 10 days from
the end of that s
emester. The full withdrawal and refund policy can be found at https://www.capitalcc.edu/student-services/refund-of-tuition-fees.
Appeals will only be considered for the following extraordinary circumstances: severe illness or medical emergency (a doctor’s note is
required), military transfer, administrative error, change of employment situation, childcare issues (documentation is required for all
circumstances to be considered) death in immediate family (documentation copy of death certificate). The following circumstances
will NOT be
considered: misunderstanding of start date or dates of class, misunderstanding of registration process, inability to transfer course, normal illness,
transportation issues, poor decision or change of mind by student regarding course selection, or dissatisfaction with course content or instructor.
Instructions for completing this form and submitting an appeal: Read the Refund Policy and determine if you meet the guidelines. If you meet the
guidelines, you must withdraw from course(s) prior to submitting an appeal. Provide all information requested below and attach
supporting documentation. Forms without documentation will not be considered. Sign, date and submit in person to the Associate Dean of
Student's Office or mail to Refund & Waiver Appeals Committee, Associate Dean of Student's Office, Capital Community College, 950 Main Street
Hartford, CT 06103. The Refund & Waiver Appeals Committee meets weekly. You will receive a written respons
e notifying you of the outcome.
STUDENT INFORMATION
First Name MI Last Name Banner ID Number
Mailing Address
City State Zip
Semester and year (please check only one):
n
Fall __________
n
Spring __________
n
Summer __________
n
Other ______________________________________
Phone Number Email Address
LIST COURSES AND REASON FOR REFUND EXEMPTION
CRN/Course CRN/Course
CRN/Course CRN/Course
CRN/Course CRN/Course
Reason (Please attach supporting documents; requests will not be considered without appropriate documentation.)
SIGNATURES
Are you a receiving financial aid? (please check only one):
n
Yes
n
No
If yes, you MUST obtain the signature of a Financial Aid staff member before submitting this form or appeal will not be
considered. Please consult financial aid staff as federal regulations may affect your account.
Financial Aid Staff Signature
Date
Student Signature
Date
Date: _____/______/_______ Adjustment: ___________________ Denied: ___________________ Response: ___________________
October2019/MS
FOR OFFICE USE ONLY
Please indicate whether or not you have been attending classes.
