Third Party Sponsor Payment Request

THIRD PARTY SPONSOR PAYMENT REQUEST
A third-party organization may sponsor a student’s enrollment by committing to paying a student's mandatory tuition and registration fees. Delgado must receive written authorization (third party contract, PO, voucher, etc) from the sponsoring agency prior to the term due date in order to process Third Party Billing. It is the student's responsibility to ensure the authorization has been received by the Accounts Receivable Department each term prior to the due date.
STUDENT INFORMATION
Name (First M. Last):*
ex. John Doe
Semester/Year:*
ex. Fall 2020
Student LoLA ID:*
ex. L00000000
Student Email:*

Confirmation Emailexample@dcc.edu
Entered:
Vendor/Sponsor Information
Company/Sponsor Name:
Company Sponsor:
Primary Contact Name:
Billing Email:
example@example.com
Comments:

SPONSOR AUTHORIZATION
Sponsoring Agency must provide an Authorization Letter addressed to Delgado Community College. All third-party authorizations must:
- Be printed on company letterhead and addressed to Delgado Community College.
- Include the Taxpayer Identification Number (TIN Number)
- Include the complete billing address of your organization, including a primary contact name (email address, phone and fax numbers)
- Include student name and LoLA ID number.
- Indicate the semester of the sponsorship.
- List all fees the organization will cover.
- Indicate the maximum amount that will be paid, if applicable
- Include any special billing instructions
- Be signed by an authorized official
Sponsor Authorization Letter *

Browse Files
(Company Letter ,PO, voucher, etc.) Cancelof
STUDENT AUTHORIZATION
Student Certification:*

I hereby certify that the attached document(s) is a true and accurate copy of the original which I have in my possession. It is my responsibility to abide by the sponsor’s requirements and notify the sponsor of any changes in my registration, enrollment, or any other information pertaining to this request.I understand that it is the responsibility of the student to provide all required documentation and required information to Delgado Community College prior to the published or assigned due date(s).I acknowledge that while Delgado accepts payment via third-party sponsorship, the responsibility for payment remains with the student. It is the student’s responsibility to monitor his/her account balance and any funding sources. If third party sponsors do not pay within a reasonable period, the student will be required to pay the full amount due.
Family Educational Rights and Privacy Act (FERPA) Release:*

I authorize Delgado Community College release necessary financial and educational information, in the manner requested, to the sponsor for the purposes of Third Party Invoicing/Payment (to include electronic transmission methods). This only applies to cases where it is mandatory for the school, in place of the student, to supply the information.
Terms and Conditions:*

I promise to pay for all fees not covered by this agreement by the published or assigned due date(s).In the event the student becomes delinquent in paying charges or defaults in repaying charges, the debts may be transferred to the State of Louisiana Attorney General’s Office, the Louisiana Office of Debt Recovery, or another external agency for collection. All collection fees incurred shall be at the expense of the student which may be based on a percentage at a maximum of 33 1/3%. If Delgado prevails in a lawsuit to collect on the student’s financial obligation, the student will be responsible to pay Delgado’s court costs, collection fees and attorney’s fees in an amount the court finds to be reasonable.
Student Signature*

Clear
Print Name*
Date Date*

MonthDayYear
Date
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THIRD PARTY SPONSOR PAYMENT REQUEST

STUDENT INFORMATION

Vendor/Sponsor Information

SPONSOR AUTHORIZATION

STUDENT AUTHORIZATION