THIRD PARTY BILLING INFORMATION FORM

SECTION A. Sponsor Information Name: Contact name: McGill Sponsor ID (if known):

SECTION B. Student Information If you want to provide authorization for more than one student please attach a list with the names, student ID numbers and maximum dollar amount for any students not listed in Section B.

Student Name: McGill ID: Program of Study:

Sponsor Authorization Number required? Yes No Sponsor Reference Number:

Authorized terms (check all that apply) fall term 20 _ _ (year) winter term 20 _ _ (year) summer term 20 _ _(year)

If the award is authorized for multiple years: From: (MM/YYYY) _____________ to (MM/YYYY) _____________

Does sponsorship require annual renewal? Yes No

We request that McGill issue T4A (Scholarship/Award Income receipt) Yes No

SECTION C. Authorized coverage Please indicate the charges which you will accept to pay for as a sponsor. A description of tuition and fees can be obtained at http://www.mcgill.ca/student-accounts/fees/.

Sponsor billing categories

Additional Information: Please note any specific coverage or dollar limitations.

Tuition

Ancillary Fees (includes society, service fees, etc.)

Health Insurance Plan (s)

Non-compulsory charges: (eg Housing, Computer Dial up charges, etc.) Specify here:

We require the student’s schedule of classes to display on the invoice: Yes No

SECTION D. For Student Account’s Office Use Only

Sponsor ID: ____________________________________________

Billing Rules:_____________________________________________________________________________________________

Student Accounts Office McLennan Library Building 3415 McTavish Street Montreal, Quebec H3A 1Y1

Telephone: (514) 398-3189 / Fax: (514) 398-2656 Cette formulaire est seulement disponible en anglais

Consent for Release of Student Accounts Information ATTENTION: McGill University

Student Accounts Office I, ,

(Please print) hereby give consent to McGill University to release information contained in my student fee account and / or student loans account to the following upon their request:

Name and Address Relationship Phone / Fax E-mail

Phone: ( )

Fax: ( )

Phone: ( )

Fax: ( )

Phone: ( )

Fax: ( )

I understand that the people listed above are not responsible for any of my University obligations and that I remain legally responsible for the payment of my fees when due. I also understand I may withdrew or modify this consent at any time by sending my request in writing to the address below. Student Number Signature Date Signed

Please print and return this consent form by mail or fax to:

Student Accounts Office

McLennan Library Building, Room MS-55 3415 McTavish Street Montreal, Québec H3A 1Y1

Fax: (514) 398-2656 Ce document est aussi disponible en français, au Service des comptes étudiants (voir au http://www.mcgill.ca/student-accounts/forms/)