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Request for Fee Waiver
Check all that apply:
□ Segregated Fees
□ Textbook Fees
□ Special Course Fees
This form must be completed for approval of all segregated fee and/or special course fee waivers defined in
UW-Stout Policy 86-45 and UWS G-29. Refer to the appropriate policy before completing the form.
Course & section
Course Title
Term offered
Reason #
Indicate reason(s) in column above, and provide justification in space below:
1. The section is offered off campus or online exclusively to students classified as customized or distance
learners.
2. The segregated fee waiver is for extramurally funded tuition (contracts or grants), and the provisions made to
cover the segregated fees are described below.
3. The section is offered in another country as part of a study-abroad program.
4. The section is offered to a special audience as part of a conference, seminar, or customized training program.
5. Textbook rental fees may be waived in course sections meeting criteria 1-4 above. Obtain Instructional
Resource Services manager's signature approval below.
Justification:
IRS approval & date: _____________________________________________________
Recommended: _____________________________________________
Department Chair
Date
___________________________________________________
Dean
Date
(Return this form to the Provost's Office for approval)
Recommendation (Office use only)
□ Approved
□
Disapproved
Associate Vice Chancellor, representative of Special Course Fee Committee:
_______________________________________________________________________________________________
Signature & date
c: Bursar’s Office
Department chair
Registrar’s Office
Bob Butterfield,Instructional Resource Services
UW-Stout Online
segfeeform.doc