2009-2010 Authorization to Apply

I. Student’s General Information (Please print or type.)

Legal Name: Last First Middle  Male Female

Last 4 digits of Social Security Number IRN Email Address

This form can also be used to change or cancel your original authorization to apply Title IV funds to your University account. A cancellation or modification
of your authorizations will be effective for disbursements processed after the date the University receives the change, and will not affect funds already
retained. I understand that by changing my authorizations I must pay for each course prior to my first date of attendance, subsequent to the financial aid
tuition deferment period.
II. Authorization to Apply Federal Student Aid and/or State Funded Student Assistance, Acknowledgment and Signature
By signing this form, I acknowledge/authorize the following:
• Changes in my class schedule, which include breaks in excess of 29 days, may result in the cancellation or revision of student financial aid awards.
• I have received and understand the University’s Satisfactory Academic Progress Policy.
• I have received and understand the University’s Refund Policy for Title IV recipients.
• I understand that I may, but am not required, to authorize the University to hold any credit balance consisting of Title IV funds posted to my student
account that exceed current charges (tuition, student fees, and other institutional charges) and to apply any Title IV funds in excess of current
charges to other outstanding educationally-related charges such as late fees or NSF fees for the current award year or loan period and apply up to
$200 of Title IV funds for similar charges from the prior award year. However, notwithstanding any authorization I provide, any remaining Title IV
credit balance will be distributed at the end of each loan period (Title IV loans) or the last payment period in the award year for which the funds
were awarded (all other Title IV funds), as required under Title IV regulations. In addition, funds will be distributed within the required timeframe
upon rescission, in writing, of this authorization.
• I understand that the interest accrued on any monies the University retains in my student account will be retained by the University of Phoenix.
• I understand that any credit balance above the amount that I authorize the University to retain will be issued to me after the University processes
each disbursement.
• I understand that although I have applied for student financial aid, I am responsible for all charges incurred while attending the University. I will,
therefore, pay any charges not covered by financial aid.
• I understand that regardless of the chosen authorizations, Title IV and/or state student assistance funds are retained at the time of disbursement to
pay current tuition, aXcess fees, rEsource fees (including state sales tax), and directed studies fees within the academic year.
• I understand that regardless of the chosen authorizations, Title IV assistance funds are retained at the time of disbursement to pay for prior academic
year tuition, aXcess fees, rEsource fees (including state sales tax), and directed studies fees, not to exceed $200.
• If I choose to manage my financial aid funds or choose to cancel my authorizations to allow the University to hold credit balances on my behalf or to
otherwise manage my funds, I must choose another payment option once the earlier of the two have occurred 1) first disbursement funds have been
received or 2) the campus deferment period has elapsed.
• I understand that I may cancel or modify my approval for any one or all of these authorizations at any time. This may be accomplished by
contacting my campus Financial Aid Department. I also understand that a cancellation or modification of this Authorization will be effective for
disbursements processed after the date the University received the change, and will not affect funds already retained.

Mark () each box to indicate your answer. We will assume any blanks equal “No”

YES NO

  I authorize the University to hold any excess Title IV funds and/or state funded student assistance on my account as a
credit balance and to apply those funds to other open allowable charges, including administrative fees and other charges
for the current award year or loan period.

  I authorize the University to hold any excess Title IV funds and/or state funded student assistance on my account as a
credit balance and to apply those funds to future tuition and fees that will be charged to my student account by the College
during the current award year or loan period.

  I authorize the University to hold any excess Title IV funds and/or state funded student assistance as a credit balance and
to apply those funds to outstanding educationally-related charges that have been charged to my student account by the
University for the prior award year not to exceed $200.

I understand if I do not authorize the above 1) the University will still retain federal funds to pay for current outstanding charges, to include tuition
charges (including state sales tax), aXcess fees, rEsource fees, and special course fees for Directed Studies; and 2) subsequent to the University
disbursing aid, I will need to pay for future courses before beginning class. By signing this form I verify that all the information reported on this form
is true and correct.

Student Name (Print)

Student Signature Date

SFA v4 6/24/2009