PLEASE PRINT OR TYPE

 

____________________________________ ___________________________________ ___________________________________

STUDENT’S LAST NAME                                     FIRST                                                           MIDDLE INITIAL

 

_______________________                  ________________________         ___________________________________

SOCIAL SECURITY #                             YEAR/TERM                                          SCHOOL/DIVISION OF LIU

 

_________________________________________________              _________________________                                 _______________________

PERMANENT HOME ADDRESS                                                                 HOME TELEPHONE                                        EMAIL ADDRESS

 

To obtain your current tuition and fees and anticipated financial aid, click on to the Student Information System (SIS) at www.liunet.edu. Please refer to the categories Summary of Your Billing, Financial Aid, Payments and Refunds and Financial Aid Details to fill in information below)

TUITION AND FEES	$___________. _______
ROOM &  BOARD	$___________._______
PRIOR BALANCE	$___________._______
TOTAL CHARGES:	$___________._______
TOTAL ANTICIPATED FINANCIAL AID	-       $___________._______
NET AMOUNT DUE	$___________._______

For Office Use Only Deferment Amount & Dates
Amount	Date
$___________	__________
$___________	__________
$___________	__________
Counselor__________

(This must be at least 50% of Total Charges. If less, please remit check, bank draft, money order or credit card authorization for the difference. If you fail to cover half your bill, the University may deny your application for a deferred payment plan)

I hereby authorize that my SFA funds be used to cover all my charges.  In return for permission to continue in attendance, I promise to pay Long Island University my outstanding balance according to the schedule mailed to me.  I understand and agree to the terms and conditions of the Deferred Payment Plan of the University and acknowledge that this agreement is a binding obligation even though I may be under 21 years of age. I further understand that if any of the financial aids listed above are canceled or reduced after the issuance of this clearance form, I am responsible for all indebtedness involved.  I agree to pay all collection costs should the University turn this account over to an outside collection agency.  I also agree to pay a $10.00 late payment fee for each delinquent payment.

 

_____________________________________________  _______________

Student’s Signature                                                                         Date

 

RETURN THIS APPLICATION  WITH YOUR PAYMENT, IF APPLICABLE, TO THE OFFICE OF THE BURSAR.  YOU MAY PAY BY PERSONAL CHECK, BANK DRAFT  OR MONEY ORDER MADE OUT TO LONG ISLAND UNIVERSITY.  YOU MAY ALSO PAY BY VISA, MASTERCARD OR DISCOVER CARD.

 

___VISA                 ____DISCOVER                    ____MASTERCARD

 

ACCT. #____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

 

EXP. DATE _____/_____   AMOUNT_________________

 

SIGNATURE__________________________________________________________________

 

After completing this form, mail to address above or FAX to (914) 251-5959

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