Whitworth University Monthly Payment Plan Application

Please print and complete this application, then mail it to:

Heartland ECSI c/o Whitworth University TPP Application
PO Box 1278
Wexford, PA 15090

If you need help completing this form, please contact ECSI toll free at 866-927-1438.

Student Information

Student ID Number:	___________________________________________________________
Name (First MI Last):	___________________________________________________________
Address 1:	___________________________________________________________
Address 2:	___________________________________________________________
City/State/Zip:	___________________________________________________________
Email:	___________________________________________________________
Home Phone:	___________________________________________________________
Work Phone:	___________________________________________________________
Fax Phone:	___________________________________________________________
Cell Phone:	___________________________________________________________

Person Financially Responsible

Name (First MI Last):	___________________________________________________________
Address 1:	___________________________________________________________
Address 2:	___________________________________________________________
City/State/Zip:	___________________________________________________________
Email:	___________________________________________________________
Home Phone:	___________________________________________________________
Work Phone:	___________________________________________________________
Fax Phone:	___________________________________________________________
Cell Phone:	___________________________________________________________

Tuition Payment Plan

Select a plan: Select One
	Description	Months	Fee	Start Date	End Date	Sign Up By
	12 Month Plan (T1112)	12	$45.00	06/10/2011	05/10/2012	05/25/2011
	10 Month Plan (T1110)	10	$45.00	08/10/2011	05/10/2012	07/25/2011
	9 Month Plan (T1109)	9	$45.00	09/10/2011	05/10/2012	08/25/2011
	4 Month Fall Plan (T11F4)	4	$35.00	09/10/2011	12/10/2011	08/25/2011
	3 Month Fall Plan (T11F3)	3	$35.00	09/10/2011	11/10/2011	08/25/2011
	4 Month Spring Plan (T11S4)	4	$35.00	02/10/2012	05/10/2012	01/25/2012
	3 Month Spring Plan (T11S3)	3	$35.00	02/10/2012	04/10/2012	01/25/2012

Student Status

To pay an amount other than the standard tuition amounts listed, please enter that amount below in the section entitled "Non-Standard Tuition."

Tuition: Select One
Academic Year ($31,830.00)
One Semester Only ($15,915.00)
Per Credit ($1,326.00) x ________________ (Number of Fall/Spring Credits) = ________________

Housing: Select None or One
Single - Academic Year ($5,834.00)
Single - One Semester Only ($2,917.00)
Double - Academic Year ($4,834.00)
Double - One Semester Only ($2,417.00)
Triple - Academic Year ($4,560.00)
Triple - One Semester Only ($2,280.00)
Theme House - Academic Year ($4,940.00)
Theme House - One Semester Only ($2,470.00)
Boppell - Academic Year ($5,290.00)
Boppell - One Semester Only ($2,645.00)

Meal Plan: Select None or One
Meal Plan A - Academic Year ($4,084.00)
Meal Plan A - One Semester Only ($2,042.00)
Meal Plan B - Academic Year ($3,812.00)
Meal Plan B - One Semester Only ($1,906.00)
Commuter Meal Plan 1 & 2 - Academic Year ($1,564.00)
Commuter Meal Plan 1 & 2 - One Semester Only ($782.00)
ommuter Meal Plan 3 - Academic Year ($800.00)
Commuter Meal Plan 3 - One Semester Only ($400.00)
Semi-Traditional Meal Plan - Academic Year ($2,698.00)
Semi-Traditional Meal Plan - One Semester Only ($1,349.00)

Mandatory Fees: (Select all that apply)

Mandatory Student Fees - Academic Year ($314.00)
Mandatory Student Fees - One Semester Only ($157.00)
Health Insurance ($427.00)

Optional Fees: (Select all that apply)

Additional Fees
Private Music Lessons: 1 Credit (per Semester) ($275.00)
Private Music Lessons: 1 Credit (per Semester per Year) ($550.00)
Private Music Lessons: 2 Credits (per Semester) ($550.00)
Private Music Lessons: 2 Credits (per Semester per Year) ($1,100.00)
Overload Fee - 1 credit over 17.0 credits ($865.00)
Overload Fee - 2 credits over 17.0 credits ($1,724.00)
Overload Fee - 3 credits over 17.0 credits ($2,589.00)
Overload Fee - 4 credits over 17.0 credits ($3,454.00)
Overload Fee - 5 credits over 17.0 credits ($4,319.00)

Insurance Waiver

Health insurance is required and cannot be waived unless the student has other health insurance. The Whitworth Health Insurance Waiver form must be completed or the insurance will not be waived. See Confirmation Billing information for Waiver form. If you have completed the Whitworth Health Insurance Waiver form, check "Waive Health Insurance" below to remove the health insurance fee from the TPP application.

	Do Not Waive Health Insurance
	Waive Health Insurance (-$427.00)

Financial Aid:
(as it appears on your award letter. Do not include Work Study.)

Your award letter includes loan amounts offered to you. All loans require paperwork which must be completed to apply for the loan funds. Include in the calculation below only those loans for which you intend to apply. If you do not intend to apply for loans offered on your award letter, do not include them below. If you have questions about loan types or amounts, please contact the Financial Aid Office at Whitworth University. If you apply for loans that are denied, you are responsible for the amount of the loan. You may contact ECSI and adjust your contract by that amount.

For 12-Month Payment Plan, you may estimate your anticipated 2011-12 Financial Aid award. Your total budget will be adjusted after your financial aid award is finalized for the coming year.

Federal Stafford Loan:	______________________
Federal Plus Loan:	______________________
All Other Loans:	______________________
Grants and Scholarships:	______________________
Outside Grants and Scholarships:	______________________

Funds from Other Sources:

Enter any other funds from sources not listed above that will reduce the Amount to Finance.

Funds from Other Sources:

______________________

Non-Standard Tuition:

Check this box only to pay an amount other than the standard tuition amounts listed above and enter the amount of Tuition and Fees below.

Non-Standard Tuition Amount:

______________________

Payment Plan Totals

Total Tuition and Fees:	______________________ (Add all Tuition and Fee options above)
(-) Less Financial Aid:	______________________ (Add all Financial Aid options above)
Total Amount to Finance:	______________________ (Tuition and Fees minus Financial Aid)
Monthly Payments:	______________________ (Total Amount to Finance divided by number of months in selected plan)
Application / Participation Fee:	______________________
First Payment †:	______________________ (Includes months past due and application/participation fee)
	† - The application fee is due immediately. If the plan has not yet started, your first monthly payment is not due until the first due date.

Payment Information

Complete your payment options below.

Recurring Direct Debit Option Please sign me up for the Recurring Direct Debit Option

By checking the above box, I hereby authorize Educational Computer Systems, Inc to automatically deduct monthly payments from the checking or savings account indicated below. This authority will remain in effect until I notify ECSI to terminate or until the Total Payment Plan Budget has been paid in full.
Account Holder Name:	________________________________________
Account Type:	Checking Savings
ABA/Routing Number:	___________________________ [Where to Find]
Account Number:	___________________________ [Where to Find]

Recurring Credit Card Option Please sign me up for the Recurring Credit Card Option

By checking the above box, I hereby authorize Educational Computer Systems, Inc to automatically charge monthly payments of the amount due to the credit card account indicated below. This authority will remain in effect until I notify ECSI to terminate or until the Total Payment Plan Amount has been paid in full.
Card Type:	Mastercard Discover
Card Number:	___________________________
Expires:	_____-________ (mm-yyyy)
Card Verification (cvv2):	___________ [What's This]
*IMPORTANT NOTICE: If you select the credit card payment option, your card account will be assessed a payment processing fee equal to 3.95% + $1.00 on the amount charged.