Fillable Adjustment Request Form printable pdf download

Adjustment Request Form

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Bursar’s O ffice

863.874.8406 | Room 1103

4700 Research Way

Lakeland, FL 33805-8531

Fee A djustment R equest F orm

Only w ithin s ix ( 6) m onths o f t he e nd o f a s emester m ay s tudents a pply f or c onsideration o f o ne h undred

percent ( 100%) r efund o f t uition a nd f ees f or t hat s emester w hen t he s tudent h as:

Withdrawn f rom o r d ropped a c ourse ( This i s a s eparate p rocess a nd a ll d ocumentation i ncluding

•

any A RC d ocumentation m ust b e a ttached t o t his f orm).

(2) T he R egistrar h as d ocumented a nd a ccepted a s a pproved o ne o f t he c onditions a s d efined b y

•

the s tate a s j ustification, a s o utlined b elow.*

Date: ______________________________________________

First N ame: ___________________________________ L ast N ame: __________________________________

ID # : _______________________________________________ Phone: ______________________________

Address: _ _________________________________________________________________________________

City: __________________________________ State: _____________________ Zip C ode: _ _______________

Applicable T erm a nd Y ear _ __________________

Check h ere f or R epeat C ourse S urcharge

*Check t he c ondition(s) t hat apply to this request ( any i nformation submitted by t he student m ay b e

verified by t he University contacting the source):

1. Illness of the student, confirmed by v erifiable written documentation from a licensed

physician (M.D.), or other certified health professional, of such severity or duration to

preclude completion of the course(s).

2. Death of the student o r an immediate family m ember; i.e., parent, step-‐parent, g randparent,

spouse, child or sibling, a s confirmed by a death certificate and an obituary clearly indicating

the student's relationship to the deceased.

3. Involuntary o r voluntary c all to active military d uty a s confirmed by military o rders.

Adjustment Request Form

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