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Leave of Absence LOA Request Form

This document is a leave of absence request form for a student seeking time off from their studies. The form collects information about the student, the dates for the leave, and the reason. It also lists acknowledgements the student agrees to regarding leaves of absence and their effects on financial aid and academic status.

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247 views1 page

Leave of Absence LOA Request Form

This document is a leave of absence request form for a student seeking time off from their studies. The form collects information about the student, the dates for the leave, and the reason. It also lists acknowledgements the student agrees to regarding leaves of absence and their effects on financial aid and academic status.

Uploaded by

thornsb1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Leave of Absence Request

This document may be submitted electronically by going to the My Financial Aid Documents section on the Financial
Aid Website at faw.phoenix.edu or fax this document to 480-598-4381.

SFS-O FA36 V3 02/27/2013
cc: Student File



Final approval of an LOA request is determined by Student Financial Services-Operations.
The following information MUST be completed by the student:
Name: Student IRN:
Leave Of Absence Start Date: Expected Return Date:
Note: Check with your advisor to confirm course start date for the earliest expected date of return.
Reason for Leave of Absence
Family Medical Leave Military
Course Cancellation/University Related
Jury Duty Natural Disaster
Extension

Other (including business and personal related leaves)
If Other, explain in detail.


Acknowledgements
I am requesting a Leave of Absence, and acknowledge the following:

1. I have read and understand the University Leave of Absence Policy in the Consumer Information
Guide (http://cdn.assets-phoenix.net/content/dam/altcloud/doc/about_uopx/Consumer-Information-
Guide.pdf).
2. A Leave of Absence must be requested in advance of the Leave of Absence start date unless
unforeseen circumstances prevent me from doing so.
3. My approved Leave of Absence expires on the expected return date noted above provided I do not
engage in an academically related activity (ARA) prior to the expected return date.
4. I will not engage in academically related activities on or after my Leave of Absence start date up to
and including my Leave of Absence expected return date noted above.
5. I understand that posting an academically related activity will result in my return to active enrollment
status with the University.
6. The University will notify me of the approval or denial of my Leave of Absence request.
7. By federal law, an approved Leave of Absence cannot exceed 180 days in a 12-month period.
8. If I do not return as scheduled, the following apply:
a. My federal financial aid will be reviewed to determine whether any financial aid funds paid to the
University must be returned to the grant/loan program source.
b. Any grace period for federal financial aid loan programs could be exhausted in whole or in part.
9. The withdrawal date and beginning of the grace period will be the last date of class attendance.
By signing this form, I am requesting a leave of absence and understand the above information.
Student Signature Date
Taylor Hornsby 9013773153
5/22/14 6/10/14
Vacation
5/22/2014

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