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# Official Withdrawal Form Student signature and date: ___ Signature Date OFFICE OF Student Name: ___ CWID: ___ THE REGISTRAR Home Address: ___ Street City State Zip Phone: 502-597-6340 Term:_____ Fax: 502-597-6239 Home 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: _____ Are you a veteran? Yes _____ No _____ Are you receiving veteran's benefits? Yes _____ No _____ Do you plan to pre-register for the next semester? Yes _____ No _____ For use by the Office of the Registrar - Do not write below this line. 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 _____ Reason: ___ student refused to complete form ___ online or virtual student other: ___ Completed by (name): ___ Date completed: Form Revised 2/2009
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