ACG 1.80 (11/93)
The
University of North Carolina at Wilmington
Transfer of Student Account Due to Non-Payment
Copies
of all correspondence between the debtor(s) and the university department
must be attached to this form and forwarded
to the Director of Accounting.
Section I. Student Debtor(s)
[ ]
All student debtors included on the attached listing.
(The listing must
provide the information shown below for each student debtor.)
OR [ ] Student debtor listed below:
1. Name of Student Debtor _____________________________________________________________
2. Social Security Number _____________________________________________________________
3. Address __________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
4. Amount Owed $___________________ Date Incurred _________________
5. The charges which gave rise to the above debt are: ________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section II. Department
6. University Department _______________________________________________________________
7. Contact Person ________________________________________ Telephone Ext. ______________
8. When collected, deposit to account number_____________________________________________
and return receipt to ________________________________________________________________
I understand
that, when an account is turned over to the Accounting Department
for collection, all correspondence between the department and the debtor
regarding
this matter must cease. Should the debtor contact us, he/she will be referred
to the
Accounting Office.
Signature of Department
Head _______________________________ Date _____________