Fillable Section VI.B. Tuition And Fees Forms (new) (Lone Star College System)

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Section VI.B. Tuition And Fees Forms (new) (Lone Star College System)

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Section VI.B Tuition and Fees
Page 4 of 5
Student Refund Request:
To be completed by the Lone Star College student requesting a refund.
Please review LSC Board Policy and Procedures for Tuition and Fees
(Section VI.B)
Student Name: _______________________________________________
Student ID: _________________________________________________
Semester and Year: __________________________________________
I am requesting a (choose one of the following):
FINANCIAL AID REFUND GENERAL REFUND
If you selected Financial Aid Refund, you must provide this form to the Financial Aid Office located on
your home campus.
If you selected General Refund, you must provide this form to the Business Services Office located on
your home campus.
Please provide the reason(s) you are requesting, or believe you are owed, a refund:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
(Attach additional pages if needed)
_______________________________ _________________
Student Signature Date
LSC Personnel Only:
___________________________________________ __________________
Signature of LSC Personnel Receiving Request Date
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ACP Participant Affidavit
To be completed by the Lone Star College student enrolled in the
Attorney General’s Address Confidentiality Program.
Student Name:
Student ID:
1. I c
ertify that I am an adult enrolled—or an eligible household member of an adult enrolled—in the Texas
Attorney General’s Address Confidentiality Program (“ACP”).
2. I hav
e read Board Policy Section VI.B.1.02, and I certify that in accordance with this section, I qualify
for tuition as an:
IN-DISTRICT
TEXAS RESIDENT
OUT-OF-DISTRICT
TEXAS RESIDENT
OUT-OF-STATE
RESIDENT
3. I
am providing a copy of my ACP authorization card to the Chief Student Services Officer, or designee,
at my home college.
4. I agree to provide a copy of my renewal to the Chief Student Services Officer, or designee, if my
authorization card expires while I am a student of the College.
5. I agree to alert the admissions office of my college, and comply with traditional address verification
requirements, if I withdraw from the ACP or do not renew my authorization card upon expiration.
6. I understand that I may be required to pay the difference between in-district and out-of-district tuition,
in-state and out-of-state tuition, or both, if I falsify any information on this form. I further understand that
I may also face disciplinary action from the College if I knowingly provide false information.
Student Signature Date
LSC Personnel Only:
Signature of LSC Personnel Receiving Request
APPROVED
DENIED (reason)___________________________________________________
__________________________________________________________________
Page 4 of 5
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Section VI.B. Tuition And Fees Forms (new) (Lone Star College System)

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Completed 4 February 2021

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