Student Bal Form

STUDENT BAL FORM

This Student Balance Form documents the account status and payment arrangements concerning tuition, fees, and other institutional charges. Completion and signature of this form constitute an acknowledgment of the outstanding balance and a binding agreement to the terms of payment and institutional collection remedies set forth below.

Student Information

Date of Birth:    Student ID:    Grade/Program:

Parent / Guardian (if applicable)

Student is under 18 years of age:    Parent/Guardian Name:

Account Summary

Previous Balance: $    New Charges: $    Payments/Credits Received: $

Outstanding Balance: $    Balance Due Date:

Payment Arrangement Options

Select desired payment option (mark one):
One-time payment of outstanding balance upon signing
Installment plan (complete details below)
Financial aid or scholarship pending; request temporary hold per policy

Number of installments:    Installment amount: $    First payment due on:

Credit/Debit Card    Bank ACH/EFT    Cash / Check

Authorization and Financial Responsibility

By signing below, the undersigned acknowledges and agrees that the person and/or guardian identified on this form is financially responsible for all amounts set forth above and any additional charges assessed to the student's account. The undersigned further acknowledges that the institution may impose late fees, interest on past due balances, place registration or transcript holds, refuse forwarding of records, and pursue collection remedies, including assignment to outside collection agencies and recovery of collection costs and attorneys' fees to the extent permitted by law.

Interest and late payment terms (if applicable): The undersigned agrees that past due balances may incur a finance charge of up to the institution's published rate and that reasonable late fees may be applied for missed installments. The institution's right to withhold services, deny registration, or restrict access to records shall apply until the account is brought current or other arrangements satisfactory to the institution are made in writing.

I authorize the institution to contact the financial guarantor(s), to furnish account information to credit reporting agencies or collection agents in the event of nonpayment, and to apply any refunds or credits to outstanding balances in accordance with institutional policy.

Accept terms: I acknowledge and accept the financial responsibility and authorization terms above.

Special Instructions / Comments

Acknowledgment of Policy

The undersigned certifies that the information provided on this form is true and correct to the best of their knowledge. The undersigned further acknowledges receipt of the institution's tuition, fee, and refund policies and understands the consequences of nonpayment as stated above.

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