T4AUTH FEDERAL PAYMENT AUTHORIZATION FORM

Please complete this form online, then print and sign.
T4AUTH
STUDENT NAME: __________________________________________
WIN: ____________________________________________________
DAYTIME PHONE: __________________________________________
ADDRESS: ________________________________________________
CITY, STATE, ZIP: ___________________________________________
WMU Student Financial Aid
1903 W Michigan Ave
Kalamazoo MI 49008-5337
(269) 387-6000
[email protected]
FEDERAL PAYMENT AUTHORIZATION FORM
Students receiving federal financial aid must authorize payment toward all current year charges and up to $200
toward all prior-year charges. You may modify or cancel your payment option at any time by contacting the financial
aid office and completing a new payment authorization form.
Current Year Charge Payment Authorization: Choose Option A or B
A ____ I authorize payment of all charges on my Western Michigan University account with funds from my federal
financial aid. This includes tuition, fees, university housing charges, meal plan charges, health center charges,
telecommunication charges, library fines, and any other charges on my account at the time my federal aid is
disbursed.
B ____ I do not authorize payment of charges other than tuition, fees, room and board on my Western Michigan
University account with my federal financial aid. I understand that I will be responsible for payment of all other
charges. Non-payment can result in holds being placed on future term registration, service charges, and other
collection actions.
Prior Year Charge Payment Authorization: Choose Option A or B
A ____ I authorize payment of up to $200 towards all my prior year charges on my Western Michigan University
account with funds from my federal financial aid. This includes: tuition, fees, University housing charges, meal plan
charges, health center charges, telecommunication charges, library fines, and any other charges on my account at
the time of my federal aid is disbursed. I understand that I will be responsible for payment of charges greater than
$200. Non-payment can result in holds being placed on future term registration, service charges, and other collection
actions.
B ____ I do not authorize payment of up to $200 toward prior year charges other than: tuition, fees, and University
room and board charges with my federal financial aid. I understand that I will be responsible for non-payment
of all other charges. Non-payment can result in a hold being placed on future term registration, additional service
charges, and other collection actions.
I also understand the above authorizations apply only to federal aid and do not apply to any state, institutional or
private donor financial aid or to any other form of payment.
STUDENT SIGNATURE: _____________________________________________________________ DATE: _______________________
Return your completed form to Bronco Express on the lower level of the Bernhard Center. You may also email or mail to the address above.
Be sure to include your name and WIN on all pages. Missing information may delay the processing of financial aid.