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: onestop@umn.edu
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.