Chargeback Submission Form

This form is for new chargeback requests

Submitter Name*

Submitter Email*

Fiscal Year

FY25

Division*

Select

Academic Affairs Area*

Select

Department Providing Service*

Departmental Contact*

If not submitter

Chargeback FDCC*

The account where expense and revenue will occur

Chargeback Name*

Description of Chargeback*

Reason for Chargeback*

Requested Chargeback Rate*

Please keep this concise and enter only one chargeback rate per submission. Example: $25/hour or Cost + 10%.

Forecasted Expenses in Current Year*

Forecasted Revenue in Current Year*

Projected Expenses in Next Fiscal Year*

Projected Revenue in Next Fiscal Year*

Include any proposed fee changes

What assumptions did you use for your projections?*

File Upload

If needed, you may submit additional documentation such as detailed budget plans, rate sheets, or any other relevant information that you would like to attach to further explain the chargeback.

Drag and drop files here or

VP Approver approval2

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VP Approver

VP Approver approval

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