Tennessee State Government



|[pic] |Tennessee Department of Children’s Services |

| |Deferral Request - DCS Tuition Assistance Programs |

DIRECTIONS: Use this form to request a deferral for a DCS Tuition Assistance Program. Please note that deferrals are granted only in extenuating circumstances and must be submitted according to the terms and deadlines specified in your signed Program Agreement. It is expected that this detailed reason/justification be accompanied by medical documentation, notes and/or correspondence from the university, employer, or agency as appropriate to support claims of hardship or extenuating circumstances.

|Date of Request: |     /     /      |Student Name: |      |

|Tuition Program: | BSW/BSSW Stipend Program MSW/MSSW Tuition Program |

| |Graduate Reimbursement Program |

|University: |      | |Duration of Deferral: |      |

|Current Scheduled semester of graduation: |      |

|Expected semester of graduation once deferral period is complete: |      |

|Deferral of Employment (BSW Students only): Yes No |

|Requested Date to Begin Employment (BSW Students only): |     /     /      |

|Detailed Reason/Justification for Deferral Request: |

|      |

|      | | | |     /     /      |

|Student’s Printed Name | |Student’s Signature | |Date |

After completion, please print this form, sign, make a copy for your records and send the original copy to:

Department of Children's Services

Tuition Assistance Program

UBS Tower

315 Deaderick Street, 7th Floor

Nashville, TN 37243

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