For Office Use Only

Date Documentation Submitted: ___ Received by: ___

Request Decision: ___ Amount of Charges Accessed: $___

Dir. of Res. Life's Signature: ___ Date: ___

Date Decision E-mail Sent: ___

Appeal Process

Date Appeal Received: ___ Date Forwarded to Committee: ___

Committee's Meeting Date: ___ Committee's Appeal Decision: ___

Date Decision E-mail Sent: ___ Date Banner System Updated: ___

Rev. March 2016