2014-2015 Alternative Loan Change Request
Please complete and return to:
Utica College, Student Financial Services
1600 Burrstone Road, Utica, New York 13502
Fax: 315-792-3368  Email: sfs@utica.edu
_______________________________________
Student’s Name
__________________________________
Utica College ID Number
__________________________________________________________________________________
Permanent Address
__________________________
Home Phone
__________________________
Cell Phone
I would like to request a total amount of $_____________ is returned to ___________________
Lender Name
according to the following schedule:
$______________ is returned/cancelled from the Summer 2014 disbursement.
$______________ is returned/cancelled from the Fall 2014 disbursement.
$______________ is returned/cancelled from the Spring 2015 disbursement.
I understand that according to the terms of my agreement with the lender listed above, I may be
responsible for repaying interest and/or fees that may have already accrued on my loan. I also
understand that I am responsible for any balance that may become due to Utica College as a
result of my request to return funds.
___________________________________________________
Student Signature
_________________
Date