Tuition Refund Plan Claim Form

DO NOT USE FOR MEDICAL WITHDRAWAL OR ABSENCE

Special form is available for medical absences or withdrawals requiring certification by attending physician.

Tuition Refund Plan

DISMISSAL OR WITHDRAWAL CERTIFICATE

To be completed by the parent or guardian

Date:

I HEREBY CERTIFY to A.W.G. DEWAR, INC. that has severed his/her connection with School/College as of

for reasons as outlined below:

I hereby authorize A.W.G. Dewar, Inc. to make settlement payable to the above School/College, such settlement to be credited to my account, with any excess to be remitted to me through the School/College.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.

	Parent or Legal Guardian or Person Financially Responsible	(SIGNATURE)
	Address

Note: This form must be returned to the School/College for transmittal to A.W.G. DEWAR, INC. as soon as possible, in any event, not later than 30 days after date of withdrawal or dismissal.

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