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Payment Explanation Form

Please read the following information and complete form below.

If you have additional credits that you expect to receive for the term which are not included on your account statement, you may deduct these amounts from the Amount Due if you submit an Explanation Form to the Student Financial Services Office. The Explanation Form is located on the left-hand side of your D-Pay window. If you calculate an amount is still due after your deduction(s) have been made, you must submit your Explanation Form and payment to Student Financial Services by the due date. You may either mail a check to Student Financial Services/Cashiers, or make an electronic payment via D-Pay.

If the total of your additional deductions is greater than the Amount Due on your account statement, no payment is required. However, you must submit your Explanation Form to Student Financial Services by the due date in order to avoid a late payment charge, or potential Check-in delays.

When an Explanation Form is submitted to the Student Financial Services Office, we verify your deductions and waive the late payment charge. If your deductions are accepted, you will be cleared for Check-in, however if we are unable to accept a deduction for any reason, an email notification will be sent to the student. It is important to note that deductions submitted on an Explanation Form will not actually change the account statement, or affect the actual balance on the student account. You are simply explaining why the full Amount Due on your statement is not being paid by you.

In addition to listing pending Dartmouth aid on an Explanation Form, pending funds from outside sources may be listed as well. Below are some examples.

(1)  Outside Scholarships – If you will receive an outside scholarship, such as National Merit, or other type of outside award, you may deduct the appropriate term amount from the Amount Due provided the funds will be paid directly to Dartmouth College.

Note: Students who will receive financial aid from Dartmouth College must report all of their outside scholarships to the Financial Aid Office. These outside funds must be included on a student's award for the current award year.

(2)  TuitionPay Monthly Payment Plan – Your anticipated monthly payments for the term should be shown on the statement if your plan is not delinquent. If they are not already shown on the statement, and your plan is current, you may deduct the applicable payments from the Amount Due and submit the Explanation Form to our office by the due date. After the applicable payments are deducted from the Amount Due on your statement, any remaining balance due must be paid directly to Dartmouth College by the due date. For more information on the Monthly Payment Plan click here

(3)  College Tuition Benefits - If you will receive a tuition benefit from another college, you may deduct the amount that you expect to receive for the term. Please be sure to complete any required paperwork to expedite the payment process. If the institution requires that Dartmouth send a special billing or complete forms, please be sure to provide this information to Student Financial Services.

(4) Alternative Loans –If you have applied for an Alternative Loan for the term, and received approval, you may deduct the net amount to be disbursed. If there are any questions regarding Alternative Loans, you may contact the Financial Aid Office directly at (603) 646-2451.

(5)  Charges in Dispute – If you are disputing a charge on your student account, such as course material fees, GLOS rent/dues, PE fees, etc., you may deduct the amount of the charge from the term balance while you are in the process of resolving the issue with the appropriate College department. Deduction is allowed for one term only.

(To find the appropriate department, you may refer to contacts for transaction questions on D-Pay)

(6) Dartmouth Student Group Health Plan (DSGHP) –If you have been billed for the Health Plan and you are in the process of submitting a waiver, you may deduct the cost from your Amount Due. There are deadlines for submitting waivers. For more information you may contact Health Services directly at (603) 646-9438 or visit their website.

 

Please list adjustments to amount due on form below

Items marked in red are required.








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IMPORTANT NOTE: If you have a charge you feel is incorrect, you need to contact the area responsible for the charge. Please use the Contacts for Transaction Questions page to assist you with this. If you can not find the charge you have a question on listed, please contact us at: student.financial.services@dartmouth.edu or call 603-646-3230.

Last Updated: 7/17/13