Chargeback Submission Form

This form is for new chargeback requests

Submitter Name*

Submitter Email*

Fiscal Year

FY24

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*

Rate(s)*

Please keep this concise. Examples: $25.00/hour or Cost + 10%

Actual Revenue in Prior Year*

Actual Expenses in Prior Year*

Carryforward from Prior Year*

Forecasted Revenue in Current Year*

Forecasted Expenses in Current Year*

Projected Revenue in Next Fiscal Year*

Include any proposed fee changes

Projected Expenses in Next Fiscal Year*

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

Send me a copy of my responses

Privacy Notice|Report Abuse