Student Aid Review for Retroactive Withdrawal

This form must accompany all petitions to the Faculty Senate for Retroactive Withdrawal

While a student at Penn State, have you ever received federal student aid (Federal Stafford subsidized and/or unsubsidized loan, Federal Direct Parent PLUS loan, Perkins loan, Pell grant, and/or a Supplemental Educational Opportunity grant)?

NOTE: Federal student aid does not include tuition remission for dependents of Penn State employees, atheltic grants, some scholarships, wage-payroll earnings, or Pennsylvania state grants.

STUDENT ACTION: Check the appropriate box and follow the related instructions.

A review by the Office of Student Aid is not required. Sign below and submit this form with your petition.

Prior to requesting a retroactive withdrawal, you must consider the financial consequences ( Follow the steps below for a Student Aid review.

1. Fill in this chart with the session(s) and year(s) for which you are petitioning for retroactive withdrawal:

Requested Retroactive
Semester(s) or Session(s) / Year(s)
e.g. FA/15
Retroactive Withdrawal

_____ /_____    _____ / _____

_____ /_____    _____ / _____

2. Mail, fax, or deliver this form to Student Aid: 314 Shields Bldg, University Park, PA 16802; Fax 814-863-0322.

3. Student aid consultation: You will be contacted by Student Aid within three weeks of the submission of this review request at the phone number or email address listed above. An appointment may be arranged for you to learn about the financial consequences. The back of the form will be completed and returned to you for submission with your petition.

**University Park Office of Student Aid Use Only**

(Aid representatives at locations other than University Park must send form to UP for completion.)

Will the student lose aid eligibility as a result of this action?

No ______ If no, sign and date the form.

Yes ______ If yes, sign and date form and notify student that he/she will lose aid eligibility and be required to repay the following aid immediately:

Semester or Session(s) / Academic Year Aid Source(s) Amount to be Repaid

This section must be completed by the student after the information has been reviewed by the Office of Student Aid.

I have reviewed the above information with a representative from the Office of Student Aid. I understand that if my retroactive withdrawal petition is approved, I will be required to repay immediately all federal aid listed above. I also understand that once my financial aid has been cancelled, this action is irreversible.

Student Aid Office Use Only

Student notified that form is ready: _____ /_____ /_____

I certify that I have reviewed the information listed above with the student and that he/she understands the impact of the retroactive withdrawal action on his/her federal aid eligibility.

Once completed, copy form (including student's signature) and send to be imaged. Give original form to student.