Central Piedmont Community College
Finance & Administrative Services
Refund Exception/Adjustment Request Form
(Internal Use Only – Not to be given to students)
The student below has requested a special permission/exception for a refund or removal of charges based on
the following information. If approved, the refund or adjustment will be processed by the cashiering
department. Please complete the entire form.
Student Name
_____________________________________
Student ID
_____________________________________
Semester
_____________________________________
Course/Section _____________________________________
Type of course:
Curriculum
Self-Supporting
Occupational Extension
75%
75%
75%
or
or
or
100%
100%
100%
This request is based on and documented by the following reason:
_______
Prerequisite Not Met
_______
Never Attended/Grade Change
_______
Technology Reasons, i.e. – difficulties with telecourse, email, computer
_______
Institutional Reasons/College Error, i.e. – may include errors in printed schedule concerning
class times, location, etc.
_______
Other ___________________________________________
Explanation:
Requested by:
Date:
This request has been approved by: (Both signatures are required)
Division Director:
Date:
Dean:
Date:
Please forward this refund request to Cashiering Dept., Central Campus for curriculum courses or to CCE
Accounting, Harris Campus for CCE courses.