Change of Status

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

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

Allowable circumstances include, but are not limited to, illness of the student or family member, need to become a caregiver or first responder, loss of childcare, economic hardship, inability to access wi-fi due to closed facilities, class transition from on ground-based instruction to distance learning, closed campus housing or other campus facilities or an increase in work hours as a result of the COVID-19 emergency.

Effective Status Change Date*

Beginning Date

End Date

Place of employment.

Comments

Request to withdraw due to the novel coronavirus disease (COVID-19)*

I certify that I was affected by COVID-19 and the information that I provided is true and correct.

I understand that 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).

Student Signature*

Date*

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