Student Tuition Guaranty Fund Claim Form

SCHEV
James Monroe Building
101 North Fourteenth Street
Richmond, Virginia 23219
Phone: (804) 225-2600
Fax: (804) 225-2604
TDD: (804) 371-8017
Web: www.schev.edu
Student Tuition Guaranty Fund Claim Form
I. General Information
The Student Tuition Guaranty Fund is designed to issue refunds of unearned tuition to students unable to complete their program of study
due to a school closure. The student had to be enrolled at the time of the closure to be eligible for the partial refund. The claim will not
include the cost of books, supplies, or fees that have been paid.
Copies of your Enrollment Agreement or contract, completed W-9, and proof of payment for all tuition payments made to the school (i.e.
promissory note, school receipt, cancelled check – front and back, credit card receipt or statement showing charge to school) must be
submitted with the claim form.
Students have three years from the date of the school closure to file a claim against the Student Tuition Guaranty Fund. If the tuition was
paid by a student loan, the refund will be sent to the lender with any remaining balance going to the student.
Student Name:
Date:
Mailing Address:
City:
ZIP
Code:
State:
Home Phone:
(
)
Cell Phone:
(
Work Phone:
(
)
E-mail Address:
)
School Name:
City:
Program of Study:
$
Program Cost
Total Tuition Paid:
Method of Payment:
Lender
Borrower Name
Last date attended:
(if different from student):
Total Loan Amount:
ZIP
Code:
State:
Enrollment
Dates
$
Total
credit /
clock hours for program completion:
Total
credit /
clock hours completed:
Outstanding Balance:
Provide a listing of all courses required for program FRPSOHWLRQ
Provide a listing of all courses student completed beforeschool closed:
to
$
$
Have you received payment from any other Student Tuition Guaranty Fund due to this schools’ closure?
Yes
No
Yes
No
If yes, provide the name of the State and payment amount:
Have you been part of any monetary settlement as a result of legal action by the school of your lender
If yes, what was the result of the settlement?
Has any part of your loan been forgiven by your lender?
Yes
No
Yes
No
If yes, how much has been forgiven?
If your tuition was paid by credit card, has the company investigated the charge?
If yes, what was the outcome of the investigation?
With my signature and under penalty of perjury, I swear that to the best of my knowledge, all information I have provided in this
document is true and accurate; and that I was a student at the above-named school at the time of its closure.
Student Signature: ________________________________________
Date: ____________________________
STATEMENT OF NOTARY
City/County of:
Commonwealth of Virginia
The foregoing instrument was acknowledged before me this:
by:
day of
, 20
, who appeared before me in this jurisdiction
(Printed Name of Individual Above)
Aforesaid and acknowledged that the information contained herein is true and correct.
I further certify that my
Commission expires
Date
(Notary Public
Notary Registration Number