Texas State University
Tuition Rebate Program – Hardship Justification
Submit this completed form to your college academic advising center and obtain written approval on this form. Attach this completed and approved form to the Tuition Rebate Program Application and submit both to your college academic advising center no later than 30 business days after the date the college dean or supervisor of the college academic advising center determines ineligibility. Note: The college dean or the supervisor of the college academic advising center requires written documentation of any of the following hardship conditions claimed.
Hardship claimed is [circle one or more]:
a. My own severe illness or other debilitating condition that has affected my academic performance.
b. I am responsible for the care of a sick, injured, or needy person and providing such care has affected my academic performance.
c. I have been performing active duty military service while pursuing a degree at Texas State.
Name: _______________________________________________ ID#: ______________________
Local Address: _________________________________________
Local Phone: _______________________________ Permanent Phone: ________________________
Semester of Graduation: _________________________
I hereby claim a hardship, as indicated above, to qualify for a Tuition Rebate, as authorized under the Tuition Rebate Program, in accordance with Texas Education Code 54.0065.
I have reviewed the student’s hardship claim and have made the following determination, as indicated:
□ Hardship Approved □ Hardship Denied – for the reasons indicated below.
Denied because ______________________________________________________________________
Dean’s or Supervisor’s name (print): ______________________________________________________
Dean’s or Supervisor’s Signature Date