FINANCIAL AID WITHHOLDING AUTHORIZATION Bursar's Office

Kentucky State University

Academic Services Bldg, 3rd Fl

400 East Main Street

Frankfort, KY 40601

Telephone: 502-597-6278

Fax: 502-597-5936

Please read the entire withholding statement before adding your signature and date to verify that you understand the terms of this authorization. You can view your student account information at http://www.kysu.edu/wired.htm. Log into WIRED and in the Student Records section, select "Account Summary and Pay by Credit Card." If you have questions regarding this form or your account, please contact an Account Specialist at 502-597-6278 or by e-mail at bursar@kysu.edu.

To fill in the form fields online, select the field and type. Print the completed form to add your signature.

Personal information

Name Social Security number Student ID number

E-mail address Phone number

Mailing address (street number, city, state, ZIP Code)

Certification

I authorize Kentucky State University to use my financial aid to pay all outstanding charges on my student account. Financial aid can include loans, grants, scholarships, or other institutional, federal, or state funds. I acknowledge any credit balance remaining may stay on my account unless I claim it. I understand that if I do not claim any credit balance, the University may earn interest on these funds, which will not be paid to me. I agree that if this aid is not directly credited to my account, I will endorse any financial aid check(s) to Kentucky State University. I will not receive any funds until all charges posted to my student account are paid in full. I understand that completion of this form does not guarantee that my student account will be paid in full. Any balance remaining after disbursement of my financial aid is my responsibility. I authorize Kentucky State University to use financial aid funds to pay any non-standard charges assessed to my student account. These charges may include, but are not limited to, the following: book charges, library fines, parking fees, late fees, and/or installment plan fees. I also authorize Kentucky State University to transfer any financial aid funds to any past due balances on my student account. I understand that this authorization will remain active on my account and is valid for as long as I am a Kentucky State University student. I understand that in order to inactivate this authorization I must send a written cancellation to the Bursar's Office at the address listed above.

Student signature Date

To request copies of this form in an alternative format, please call the Disability Resource Center liaison for financial aid at 502-597-5093. Kentucky State University is an equal opportunity employer and educator. FA850 12/09 online