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UNIVERSITY OF MAINE
STUDENT RETROACTIVE REFUND APPEAL

Refund Policy Appealed (Check One)
Print      Add/Drop Refund Policy
     Withdrawal Refund Policy

Part A - To be Completed by Student

I hereby request the Bursar or designee to grant an exception to the established refund policy based on the circumstance outlined in my attached written statement.

Student's Name   Social Security Number   Student's Signature & Date
Address:     Phone #:      

Part B - Financial Aid Review (if applicable)

     Appeal Has No Effect on Financial Aid

Date:

  
     Financial Aid Will Be Affected As Follows:    
         
         

Financial Aid Office Contact Signature

Part C - To be Completed by University Administrator

 
TERM:      FALL    SPRING    SUMMER   YEAR
CRN#'s:                

Credit Hours

 :  
Course Designator(s):              

Effective Date:

    
Recommendation:


 

     

Printed Name & Title

  

Signature of Administrator/Designee

 

Date

Part D - To be Completed by University Administrator

Appeal is:      Approved    Not Approved (see remarks)


 

Bursar or Designee   Date

Distribution:  Original - Bursar, Copy - Student, Copy - Originating Office (Disposition Copy), Copy - Originating Office (File Copy)