Fillable Printable Breach Of Contract Form - Missouri Southern State University

Breach Of Contract Form - Missouri Southern State University

REQUEST TO BREACH/BUYOUT HOUSING CONTRACT

Name Student S # ______________________

Room Assignment Phone #

Home Address

City State Zip Code

Date of Requested Move

Reason for Requesting Breach of Contract (mark all that apply):

GraduationTransfer to another collegeDisciplinary

Withdrawal Physical/Psychological Health Financial Aid

Marriage $600 BuyoutOther

Explanation for above (required): _________________________________________________________

_______________________________________________________________________________________

Note:Completion of this form is not a guarantee of its approval. If approved, this form will serve as notice to Residence Hall staff. No such

approval will be given without completion of this form. The $150 housing deposit will be forfeited. Students not approved will continue to be

financially responsible for all room and board fees.

Buyout Agreement: I understand that the buyout charge will be applied to my account when request is approved, and the housing deposit

will be forfeited.

Signature Date

Approved Denied

Student Affairs Office(Billingsly Student Center 347) Date

Comments:

Revised 1/14