Official Withdrawal Form
Student signature and date: ___
Student Signature and Date
Signature Date
<div style="text-align: center;"><img src="imgs/img_in_image_box_1_21_1599_61.jpg" alt="Image" width="99%" /></div>
Student Name
CWID
Student signature and date: ___
Cij Home Address: Street City State Zip
Home Address
OFFICE OF Student Name: ___ CWID: ___
THE REGISTRAR Home Address: ___ Street City State Zip
Term:_____
Term
Home Phone: (___) ___
Area Code Home Phone
Home Phone
Phone: 502-597-6340
Fax: 502-597-6239 Home Phone: (____) _____
Email address:_____
Area Code Cell Phone
Cell Phone
Email address
Cell Phone: (___) ___
Students who receive Title IV financial aid Pell Grant, Federal SEOG, Federal Perkins Loan, Federal Direct or PLUS loans and withdraw from the University are subject to the Return of Title IV Funds regulations. Students with funds from any of these programs “earn” their financial aid dollars while enrolled. If a student withdraws prior to completing 60% of a term, a prorated portion of his/her federal financial aid dollars must be considered “unearned” and returned to the federal programs. Unearned financial aid dollars returned to the federal programs could cause students to owe the University a significant amount upon withdrawal. Failure to return aid due back to their federal programs will result in loss of eligibility for federal financial aid assistance. Unpaid delinquent amounts may result in collection procedures.
The student will be responsible for any outstanding balance. Withdrawal does not cancel a bill.
I have read this statement and understand it. Student's initials: _____ Date: _____
I have read this statement and understand it. Student’s initials
Date
Are you a veteran?
Yes _____ No _____
Yes
No
Are you receiving veteran's benefits?
Yes _____ No _____
Yes
No
Do you plan to pre-register for the next semester? Yes _____ No _____
Yes
No
For use by the Office of the Registrar – Do not write below this line
For use by the Office of the Registrar - Do not write below this line.
Term: _____ Reason(s) for withdrawal: _____
Term
Reason(s) for withdrawal
If the student refuses to complete the withdrawal form or is at a distance from the University, someone in the Office of the Registrar will complete the form.
This form has been completed without the student's signature? Yes _____ No _____
Yes_4
No
Reason: ___ student refused to complete form ___ online or virtual student other: ___
Reason [1]
student refused to complete form
Reason [2]
other
Completed by (name
Completed by (name): ___
Date completed
Date completed:
Form Revised 2/2009
WWW.KYSU.EDU
Kentucky State University is an equal educational and employment opportunity/affirmative action institution