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Student Explanation Form

Please list items which explain the difference between your payment and the amount due. Please note that resolution may require you to contact the department responsible for the item involved. Late charges are assessed if payment and an adequate explanation form have not been received by the due date.

Please list adjustments to amount due on form below

Items marked in red are required.

Student name (from statement)

Dartmouth ID Number (from statement)

Amount due on statement

Description	Amount
Total of all items
Amount you paid

Please provide your e-mail address:

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.