Lottery Leave of Absence Request

APSU Tennessee Education Lottery Scholarship (TELS)
Leave of Absence Request Form
Complete the following information and return to the Office of Student Financial Aid and Veterans Affairs,
Room 216, Ellington Building. Deadline for submission of this form is the 14 th day of the semester in which you
are requesting a leave of absence.
Name: _______________________________________ APSU Student ID #: ___________________________
Address: _____________________________________ Telephone #: ________________________________
City: _________________________________________ State and Zip: _______________________________
For which semester are you requesting a leave of absence?
Fall
Spring
Summer
Indicate the reason for this request:
Personal Illness
Illness or death of immediate family member
Extreme financial hardship
Military mobilization
Participation in an internship or co-op program required or encouraged as a part of the student’s
academic program
Religious commitments required of all students of my faith
Other extraordinary circumstance beyond student’s control
Required Documentation:
Appeals will not be reviewed without verifiable documentation.
1. Attach a detailed letter, typed or legibly written, explaining your petition for a leave of absence.
2. Enclose copies of supporting documentation. Examples of appropriate supporting documentation are
included on the back of this form.
Please read and initial the statements below:
_____ I verify that all of the above statements, my attached letter and all attached supporting documentation
are true and accurate.
_____ I understand that, if my request is approved, my TELS award will be reinstated beginning the semester I
resume my education. If this request is denied, and I take a leave of absence, I will lose my TELS award
for all subsequent semesters. Denial of my request can be appealed through the TELS appeals process.
Student Signature: __________________________________________ Date: _______________
For Office Use Only **Print SZATELS screen and attach to form.**
Request is: Approved Denied
Signature of Lottery Staff: ____________________________________ Date: __________
Comments: _______________________________________________________________
_________________________________________________________________________
Initial after updating: Egrands_____ SZATELS_____ RPAAWRD_____ Decision Letter_____

Reason for Leave of Absence
Major Illness or Injury of Student
Major Illness, injury, or Death of an Immediate
Family Member (Parent, Sibling, Spouse, or Child)
with Whom the Student Lives
Extreme Financial Hardship of Student or
Immediate Family with whom the Student Lives or
Upon Whom the Student is Dependent
Fulfillment of Religious Commitment of all
Students in a Specific Faith
Military Obligations of Student or of Immediate
Family Member with Whom the Student Lives or
Upon Whom the Student is Dependent
Participation in an internship or co-op program
required or encouraged as a part of the student’s
academic program
Appropriate Documentation Examples
Statement from a medical doctor or other licensed
healthcare provider indicating the type of illness or injury,
the date of onset, and whether or not the student is still
under medical care. This statement must be on appropriate
letterhead.
Police accident report.
Statement from a medical doctor or other licensed
healthcare provider indicating the type of illness or injury,
the date of onset, and whether or not the student is still
under medical care. This statement must be on appropriate
letterhead.
Police accident report.
Copy of obituary.
Copy of an official death certificate.
A letter explaining, in detail, the nature of the extreme
financial hardship and what action the student and/or family
is taking to deal with the situation.
Documentation of the current family income, outstanding
medical expenses not covered by insurance, etc.
Copies of court documents that will support the basis for
appeal.
A letter indicating the name of the religion, how and when
the student became a member of that religion, and the
contact information of the local branch with which the
student is affiliated.
A letter from a cleric or officer of the local branch of the
religion stating what type of religious commitment is
required of the student, when the commitment must be
fulfilled, the time frame for fulfilling that commitment, and
who is expected to fulfill that commitment.
Copy of activation letter for student/immediate family
member who is activated.
Signed documentation/letter from your academic advisor.
(REV: 03.08.13)
Office of Student Financial Aid & Veterans Affairs
Attn: Lottery Scholarship Appeals
Ellington 216
P.O. Box 4546 * Clarksville, TN 37044
Telephone (931) 221-7907 * Fax (931) 221-6329 * Toll Free (877) 508-0057
http://www.apsu.edu/financialaid/
Email: sfao@apsu.edu