The University of Maine - Bursar's Office - Retroactive Refund Appeal Form

Appeal Has No Effect on Financial Aid

Financial Aid Will Be Affected As Follows:

Financial Aid Office Contact Signature

Please	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)

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)