student services fee waiver request
Transcription
student services fee waiver request
STUDENT SERVICES FEE WAIVER REQUEST DIRECTIONS Return this form To request a Student Services Fee waiver, fill out the form completely and return it to the address at right. You may request a Student Services Fee waiver for various reasons, including not being enrolled in a degree program, being enrolled in an off-campus program (such as an out-of-state Ph.D. dissertation or special instructional program), an inaccurate assessment of the fee against your account, or your individual circumstances. A request for an individual waiver may be submitted for the current term only, except in the case of an inaccurate assessment. Requests must be submitted by within 60 days of the beginning of the term for which you are requesting a waiver. Decisions will be made within five (5) business days and emailed to you, unless you indicate another communication preference below. Contact the One Stop Student Services Center at the phone number at right if you do not hear from us within that time frame. In person on campus: 333 Robert H. Bruininks Hall 130 West Bank Skyway 130 Coffey Hall By mail to: One Stop Student Services Center University of Minnesota, Twin Cities PO Box 835 Minneapolis, MN 55440 Questions? Phone: 612-624-1111 TTY (hearing impaired): 612-626-0701 Email: [email protected] Web: onestop.umn.edu To ensure privacy online, open in Adobe Reader (free at Adobe.com). Please add the required signature(s) in blue or black ink. Part 1. Student information Name (last, first, middle initial) University ID Address (street, city, state, ZIP Code) Preferred communication method (Check one and provide your phone number or University email address): @umn.edu University email: Daytime phone: Part 2. Waiver request information Check the box for the semester and complete the year for which you would like the fee waived. Please check only one box. fall 20____ spring 20____ May/summer 20____ Please provide the specific reason for your request: Part 3. Certification I understand that I am requesting a waiver of the Student Services Fee and that, if the request is approved, the Student Services Fee will be waived for the one semester/year indicated above. I will not have the use of the services provided by the Student Services Fee (ex.: University Recreation Center, legal services, Boynton Health Clinic). If my request is denied, I understand that I must pay the Student Services Fee. Student signature Date for office use only reviewed by item type 100170090001 term to which waiver is being applied *FA923* approved yes date reviewed no date waiver applied To request copies of this form in an alternative format, please call a Disabilities Services liaison at 612-625-9578. The University of Minnesota is an equal opportunity employer and educator. This form is printed on paper made from no less than 20 percent post-consumer waste. FA923—Page 1 of 1 5/15 Please recycle.