DEPARTMENT OF EDUCATION

~ u pennsylvania DEPARTMENT OF EDUCATION

Student Bond Claim Form Instructions

Pittsburgh Career Institute

? Complete, sign, and date this form ? Provide copies of the followed required documents/information:

(do not send originals, documents will not be returned) o Current transcript o Enrollment agreement o Program description from the school's catalog o Financial aid documents o Account statements from the school o Evidence of payments made

? Must be received in our offices no later than January 6, 2023, mail/deliver to: Pennsylvania Department of Education State Board of Private Licensed Schools 333 Market Street, 12th Floor Harrisburg, PA 17126

A claim may be submitted for a refund of some of the tuition paid for courses you paid for but were unable to complete due to school closure. You can claim a refund of tuition paid by cash, check, or credit cards. You may claim a refund of a student loan if you are not eligible for loan forgiveness. You cannot claim a refund for grants. Claims will be adjudicated by the bonding company. You may not receive payment for the full amount claimed.

State Board of Private Licensed Schools Division of Law Enforcement Education and Trade Schools, Bureau of Postsecondary and Adult Education

Harrisburg, PA | 717.783.8228 | education.PLS | RA-PLS@

Student's full name: Mailing address: City, State, Zip code: Cell phone: Email address: Enrolled program: Start date:

Student Bond Claim Form

Pittsburgh Career Institute Student ID number:

Alternate phone:

Anticipated graduation date:

Total amount of tuition paid for currently enrolled classes that you were unable to complete due to school closure: $

Total amount of refund claim: $

Total amount paid by cash, check, or credit card: $ Total amount paid by grant awards: $ Total amount by student loan: $ Other: $

If `Other' payment is indicated, explain payment typed:

What types of loans did/do you have? (Personal bank loan, private loan, subsidized student loan, unsubsidized student loan, etc.)

List the courses you paid for, but did not complete:

Describe why you were unable to complete the courses:

Will you participate in a `teach-out' with another school to complete your program?

If so, name of school:

Student signature: (Electronic signatures will not be accepted)

Date:

Form and required documents must be received in our offices no later than January 6, 2023

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