AGREEMENT RELEASE INFORMATION HOUSING AND MEAL PLAN

Please review this information carefully. To be considered for release, you must submit a complete packet of
documentation. If your petition for release is based on lifestyle or residence hall issues, we recommend you
meet with your Community Coordinator (CC) prior to submitting this packet. All information submitted is
confidential.

Petition Process
1. Review this information and gather the necessary documentation.

2. Provide a written statement of why you are petitioning to be released.

3. Submit your completed packet to the Housing & Food Services office located on the first floor of Marian
Spencer Hall. The date your completed packet is submitted will be used to determine any refund if you are
released in accordance with the schedule outlined in the Housing Agreement terms and conditions. An
incomplete packet will only delay your case and reduce any potential refund if you are released. A
packet determined to be incomplete will be returned to you.

4. After you submit your packet, you may be contacted to schedule an appointment with the Housing & Food
Services representative reviewing your petition. In most cases petitions are processed within 10 working
days.

5. Notifications are sent to the student’s University issued email account.

6. If your petition is denied, you may appeal within 5 working days. Information on the appeals procedure will be
provided to you in your notification letter.

Housing Agreement (Room and Meal Plan) Release

Release from the Housing Agreement is considered on the following grounds: financial, medical/psychological,
marriage, and other. Students who are released from their Agreement (room and meal plan) must complete a
proper check out within one week of release to avoid continuing room and board charges.

Financial

To be considered for release on financial grounds, you must document a significant and unanticipated change in
your financial circumstances incurred since the time you signed the agreement. You must present the following
information:

1. The comparison sheet between current living expenses and anticipated expenses in your proposed
alternative.

2. If you are a dependent student as defined by the Financial Aid office, copies of your own and your parent’s or
guardian’s W-2’s and tax returns for the previous year, along with a complete listing of your current financial
assets (e.g. checking/savings statements) and obligations (e.g. bills, loans, etc.)

3. If you are an independent student, your own W-2’s and tax returns for the previous two years and a complete
listing of your current financial assets (e.g. checking/savings statements) and obligations (e.g. bills, loans,
etc.)

Revised 02/18
4. Documentation regarding the change in the student’s or other financially responsible person’s circumstances,
for example:

Employment loss: Letter from employer stating and circumstances of termination, date of notification of
termination, length of layoff, and any benefits received.

Unforeseen expenses: Bills from auto repair, home repair, health care, or other services, along with
insurance and benefits reimbursements, co-pay requirements, etc.

Medical/Psychological

To be considered for release on medical/psychological grounds, you must document medical or psychological
conditions affected by residence hall life. Your physician must complete and return the MEDICAL
DOCUMENTATION form. Please note that all medical documentation is subject to review by Disability Services.
As most people in the Cincinnati area suffer allergies no matter where they live, allergies are not
considered an acceptable reason for release. This is supported by University Student Health Services.

Marriage

To be considered for release on grounds of marriage, you must document your marriage or impending marriage
to occur within two (2) weeks. You must present the following information:

1. A marriage certificate for a completed marriage; or a marriage license for an impending marriage within two
academic weeks. Certificate of completed marriage must be presented within 30 days.

Other

For all other petitions, you must meet with the Associate Director of Housing & Food Services to determine what
documentation is needed. The desire to live elsewhere, roommate conflicts, or hall related concerns are
not grounds for release.

Meal Plan Release

Release from the meal plan is considered on the following grounds: financial, dietary, and other.

Financial
Submit the information outlined in the Housing Agreement Release financial section listed above. Petitions
without documentation will be considered incomplete and returned to the student.

Dietary Religious
To be considered for release on dietary grounds, you must document medical or religious concerns that you
believe cannot be met by the meal plan.

1. For medical concerns, the MEDICAL DOCUMENTATION form included in this packet must be completed by
your doctor and submitted with the petition. This completed packet will be forwarded to Disability Services for
a recommendation. Upon receipt of the recommendation, you will be advised of the decision in a written
notification letter sent to your UC email address.

2. For religious concerns, outline your dietary needs and include documentation from your clergy with the
petition.

3. For reasons other than medical or religious, please provide a detailed explanation and any supporting
documentation in your written statement. You may be contacted to schedule a meeting to discuss you
scenario in more detail. In some cases your needs may be able to be met via special arrangements.

Revised 02/18
 Petition Information Form

Bipal Goyal
Name: _______________________________Student 13441542
ID#: M________________
(513) 641-8156
101 W Daniels St, RM 670 ___________________________
____________________________ 30 June 2000
_______________________
Current Hall Address Phone # Date of Birth
goyalbl@mail.uc.edu
_________________________________
UC Email Address

Kha 1/80, Mathmukteshwor Marga Kathmandu Bagmati 44614

Permanent Address: ________________________________________________________________
Street City State Zip

Rank:  Freshman  Sophomore  Junior

 Senior  Graduate  Co-Op

Financial Classification:  Independent  Dependent

List the semesters in which you have lived in UC Residence Halls:

Fall 2019
__________________________________________________________________________________

Release sought for: Type of Petition:

 Fall Room and Board  Meal Plan Only 

 Spring
 Summer Release sought for: Release sought for:
 Financial  Financial
 Marriage  Dietary
 Medical/Psych.  Other (reason below)
 Other (reason below) _____________________
_____________________
_____________________
_____________________

Please describe your reasons for requesting a release on the back of this page.

I understand the attached instructions and that it is my responsibility to develop a complete petition
packet in accordance with the directions on the Agreement Release Information sheet. Further, I
understand that my petition is a request and that I am bound to the terms of the Agreement unless I
am formally released.
Digitally signed by Bipal Goyal
Bipal Goyal Date: 2019.12.13 17:06:22 -05'00'
_________________________________________________________ 12/13/2019
_____________________
Student Signature Date

Please submit form via email to uchousing@uc.edu. Additional options

include: fax: 513-861-6816, mail: 2911 Scioto Lane, Cincinnati, OH 45221, or in
person to the Housing front desk on the first floor of Marian Spencer Hall.
Revised 02/18
 MEDICAL DOCUMENTATION FORM
(To be completed by Physician)

______________________________________ is petitioning for a release from the Housing and/or

Meal Plan Agreement. This Agreement is binding for the academic year. The information you
provide will help us to determine whether or not we release the student from this Agreement for
medical reasons. Please complete this form in its entirety.

Medical Condition:
Please explain the student’s medical condition as related to release from the Housing/Meal Plan
Agreement.

What is the housing/meal plan change you are recommending?

Why?

I. Environment (Housing Release)

A. Please explain the effect of residence hall living on the student’s condition.

B. Please comment on the suitability of other residence hall living options, i.e. quiet
floors, single rooms, academic floors, etc.

C. Please comment on the advantages of the living space proposed by the student.

Revised 02/18
II. Restricted Diet (Meal Plan Release) – Please list any dietary restrictions as well as foods
that the student may eat (use brand names if appropriate). Use the back of form if
necessary.

By my signature, I certify that the above information is correct and that my records and
diagnostic tests confirm the need for the change requested. I agree to release those records
to the Director of University Health Services (513-556-6016) upon request. I understand that
the medical records I send will be kept in the student’s confidential medical file.

____________________________________ ____________________________________
Physician’s Signature Name of Physician

Date Signed (Area Code)Phone Number

____________________________________
Address

By signing below, I agree to have my doctor release any medical records requested to the
Director of University Health Services upon request. I understand that the medical records I
send will be kept in my confidential medical file at University Health Services.

__________________________________ __________________________________
Student’s Signature Date Signed

Please submit form via email to uchousing@uc.edu. Additional options

include: fax: 513-861-6816, mail: 2911 Scioto Lane, Cincinnati, OH 45221, or in Revised 02/18
person to the Housing front desk on the first floor of Marian Spencer Hall.