Petition For Emancipation Page 2
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1
2
3Source/Employer
Address
Dates
Total for Year
_____________________ ___________________________
_______________ ____________
_____________________ ___________________________
_______________ ____________
_____________________ ___________________________
_______________ ____________
e. List and provide photocopies documenting all major expenses for the past 12 months:
Room per month (rent, mortgage payments, etc.):
$_________
Total for the year:$______________
Board per month (food, utilities, etc.):
$_________
Total for the year:$______________
Tuition and Fees per term:
$_________
Total for the year:$______________
Miscellaneous expenses per month:
$_________
Total for the year:$______________
Total Yearly Expenses:$ ___________________
Wait to sign this petition until you have completed the petition, attached copies of supporting documentation AND you are in the presence of
a Notary Public.
I hereby swear/affirm that the answers given in this petition are accurate and complete, and that all documents attached hereto are true and
unaltered copies of the original documents requested. If my circumstances change, affecting the tuition status requested by this petition, I
agree to notify the Office of Admissions and Records in writing within 15 days after such change.
________________________________________
__________________
Signature of Petitioner (Student)
Date
State of (__________________________________)
County of (________________________________)
Sworn to and subscribed before me this
_____________day of __________________,20___
__________________________________________
Signature of Notary Public
My Commission Expires: ______________________________________(SEAL)
DO NOT WRITE IN THIS SPACE
:
Place received stamp here and initial
Emancipation Classification Decision:
Approved
Denied
Date:____________________
Effective Date: ________________Term ______________
Decision made by:_________________________________________
Additional Information:
_________________________________________________________________________________________________________________
_______________________________________________________________________________________________________
2 of 3
Revised 8/8/2005
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