October 2020

Student Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Telephone (Home) Phone

Cell/Work Phone

Program Title*

Last Date of Attendance*

Description*

Is your withdrawal related to the novel coronavirus disease (COVID-19)?*

Yes
No

For students whose withdrawals are related to the novel coronavirus disease (COVID-19) Direct Loan funds received for the period will be canceled, The period will not count toward the student’s Subsidized Loan usage for purposes of the 150% Direct Subsidized Loan Limit, and Pell Grant funds received for the period will be excluded from the student’s Lifetime Eligibility Used (LEU).

Please explain how COVID- 19 caused you to withdraw from MTI.

Effective Status Change Date*

Beginning Date

End Date

Place of employment.

Comments

Student Signature*

Date*

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