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Currency [0]/Explanatory TextG5Explanatory Text % 0Good;Good  a%1 Heading 1G Heading 1 I}%O2 Heading 2G Heading 2 I}%?3 Heading 3G Heading 3 I}%234 Heading 49 Heading 4 I}% 5InputuInput ̙ ??v% 6 Linked CellK Linked Cell }% 7NeutralANeutral  e%"Normal 8Noteb Note   9OutputwOutput  ???%????????? ???:$Percent ;Title1Title I}% <TotalMTotal %OO= Warning Text? Warning Text %XTableStyleMedium2PivotStyleLight168dq:Fc-2NWgFSWc-2NWgFSW̙̙3f3fff3f3f33333f33333\`\ InstructionsEdFee or Waiver FormzBudget Template Sample~ Waiver List  ;@   ;5I. Request to:Establish a Campus FeeAdjust a Campus FeeII. Name of Fee:III.IV. Current fee:$_________________perV.(if applicable) Proposed fee:$_________________ Proposed effective date:VI.8Short narrative regarding description or purpose of fee:VII.VIII.Budget: IX. Submitted by:____________________________Department RepresentativeX. Dean/DirectorVice President8________________________________________________________ Fee Type:Course Material Fee Field TripOther(page 2 required)______________________________Recommended for Approval by:XI. PresidentFEE TYPE FULL WAIVERPARTIAL WAIVERApplication Fee$&State University Fee (.1 thru 6 Units)&State University Fee (6.1 units above)Foreign TuitionNon Resident Tuition Facility FeeI.D. Fee I.R.A. FeeStudent Union Fee A.S.I. Feeterm academic year]or only part of the fee. If the waiver is partial indicate the dollar amount of the fee thatAMOUNT OF FEE TO BE WAIVEDOTHER:#List the name of the fee or waiver.mGive a brief narrative of the description and purpose of the fee. You may attach additional pages if needed.prequired. The signed form with attachments is to be forwarded to the chair of the campus fee advisory committee unit/Course{The campus fee request form is to be used for any fee request, including new fees, existing fee adjustments or requests to |be forwarded to the chair of the campus fee committee for review and recommendation. Upon the approval of the fee committeeestablish a fee waiver. When the form is completed, including appropriate signatures from the requesting department, it should approved request.}List proposed effective date. Make sure the form is submitted for approval well in advance of the term for which the fee is requested. No charges will be posted once fees have been assessed for the term. No retroactive fee collection will be allowed.}Signatures of department chair or department representative, the dean or director and the Vice President for the division are~Budget: Attach a revenue and expenditure budget plan covering three years of expected activity. For a fee adjustment, attachvThe signed form with attachments is to be forwarded to the chair of the campus fee advisory committee for their reviewNand recommendation. Once the signed form is received the fees may be charged.LList the current amount being charged, if applicable and the proposed fee. UCheck the fee type and specify the name of the fee requested. (i.e.:Biology 315 etc.)s the most current year budget and two projected years for the fee supported activity. See budget template example.YEAR 1REVENUE!Annual # students X Annual fee = EXPENDITURES Payroll Supplies & Services Equipment Other (specify)Total ExpensesOther Revenue (specify) Total RevenueNet year 1 (revenue - expenses) Repeat for year 2 and year 38Authorization (Education code #, Executive Order # etc.)C(If fee waiver, copy of appropriate authorization must be attached)YPlease site the authorization if applicable and include copy of authorization document: >for example Ed Code #, Title 5 section, Executive Order # etc.If waiver of Health Services Fee is requested, it must be approved by the Student Health Outreach Team and if waived you must indicate if health services will be provided, at no cost, to those students receiving the waiver.]For each fee type, check the appropriate box indicating if the waiver is for the complete feeZis to be waived. Waiver of Health Service fee must be approved by the Student Health ]Outreach Team. If Health Service Fee is waived indicate if health services will be provided.]Health Service Fee Service Provided _____Not Provided_____46=>44 Cafeteria Building, 654-2161$Chair, Campus Fee Advisory CommitteeDate( Date:____________Phone _________'_______________________________________hFor new fee request, attach a revenue and expenditure budget plan covering three years of activity from lproposed effective date. For fee adjustment, attach a revenue and expenditure budget plan covering the mostfrecent year and two projected years for the fee supported activity. (See budget template attachment)u In order to ensure all approved requests are processed accordingly, the following procedure has been established:PROCESSING APPROVED REQUESTSl 1) After President signature, all requests are returned to the Student Affairs Office for distribution. 2) Student Affairs will provide copies to: AVP of Fiscal Services, Student Financial Services, Academic Scheduling, DepartmentS Representative (original requestor) and Department Administrative Support.` the fee is properly assessed per the proposed effective date and monitor fees received.responsible for assuring that appropriate consultation occurs prior to adjusting any fee and before requesting the Chancellor toaestablish a new fee. To facilitate this process, please provide the information requested below:ythe fee request will be forwarded to the President for his final approval. No fee will be charged prior to receiving theL`Check the appropriate box for your request. If the "Waive Fees" is checked, page 2 is required.We that the fee is properly assessed per the proposed effective date and monitor fees received. 3) It is the responsibility of the requesting department to work with Academic Scheduling and Student Financial Services to ensureKVice President for Student Affairs & Chair of Campus Fee Advisory CommitteePLEASE SUBMIT SIGNED FORMS TO:Y 1) Requestor/Department will be notified of Campus Fee Meeting date for presentationApprovedDeniedReason:qIn order to ensure all approved requests are processed accordingly, the following procedure has been established:l 4) After President signature, all requests are returned to the Student Affairs Office for distribution. 5) Student Affairs will provide copies to: AVP of Fiscal Services, Student Financial Services, Academic Scheduling, Department 6) It is the responsibility of the requesting department to work with Academic Scheduling and Student Financial Services to ensure thatm 2) Vice President for Student Affairs will forward committee recommendation via memorandum to President.D 3) President will approve & sign and return to the VPSA Office4Date of Last Fee Update: ______________ (Term/Year)In accordance with the provisions of the Chancellor's Executive Order 1102 (supercedes EO 740, 1034, 042, and 1054), the President is Waiver Fees4 4pu566/877g84V;> ?C @( DEr!IKRNcc PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VN$BRvZH MNl4 p:̉ CbÝ V*ڒ! cyg$wS.QD[@o¶Vi'tJCFZe_(3xL!C8;kNLՈ\1,5'r!VO. 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