The University of Memphis

Request for Departmental Tuition Assistance

Submit completed form via the form upload at

This form should be used to request tuition/fee assistances to be paid by department and/or grant index. Beginning Fall 2021, this form is for undergraduate students only! For Graduate student tuition assistance, please submit Graduate Scholarship request thru the eContract online request system at

Please allow 3-5 business days from date received in University & Student Business Services for processing requests thru the scholarship office. Please check the USBS Web site for the fee payment deadlines for each term. Completed form can be e-mailed to (Form should be scanned & attached to email.) For best results, printing should be done with landscape format.

Term (Ex: Spring 2020) Student Name Student U# Maximum Amount of Waiver Index To Be Charged for Waiver Fund Org Account Program Student UM Employee? Y/N

Requested By: Department: Date:
Requester Phone #:

Approver: Approver Phone #: Approver Signature:__________________________________

(This person must be listed as an Authorized Signature for the org, and approver must sign in order for this form to be processed by USBS)


Submit completed form via the form upload at
  USBS Use Only

Received on (date) _____________________________ Processed (initial and date) _______________________________

The University of Memphis is an Equal Opportunity/Affirmative Action University.