UNIVERSITY OF PITTSBURGH FORM INSTRUCTION GUIDE FORM TITLE: FEES AND DEPOSITS REQUEST NUMBER: FORM 0116 PITT 1860 PROCEDURE: 09-05-03 TO BE COMPLETED BY THE ORIGINATOR: 1. Date of request. 2. Effective date (MM/DD/YY) or term (YYN) for implementing new or revised fee/deposit rate. 3. Check to indicate whether fee or deposit is course related, major related, or other, e.g., application fees, service fees, etc. Then indicate: New Fee or deposit to be created Change Increase or Decrease to an existing fee/deposit. 4. Name, campus address, and campus telephone number of originator of request. 5. Name of Responsibility Center and Department administering the fee or deposit. 6. Description of the proposed use for the fee or deposit, e.g., University fee, academic fee or deposit, service fee, professional and informal educational program fee, etc. 7. Proposed dollar amount of fee or deposit. 8. Existing four-digit ISIS fee code. 9. Check one to indicate whether approval of the request will result in an increase, decrease in the budget (i.e., after requests submitted after budget approval), or no change in the budget. If the fee or deposit results in a budget increase or decrease, complete and attach a Budget Modification Request form. 10. Dollar amount of budget change. 11. Proposed Account Number for depositing fee or deposit income. For fees and deposits not associated with specific courses or majors, skip to step 17, Approvals. **FOR COURSE AND MAJOR FEES, COMPLETE THE REVERSE SIDE OF THIS FORM** Course Fee Data 12. Check only one, to indicate: Fee assessed for every course taken - The course should be assessed for each course associated with this fee, and a student will be charged multiple fees if more than one of these courses is taken in the same term. Fee assessed only one time per term - The student is to be assessed the course fee only once per term, regardless of how many courses associated with this fee are taken in the same term. 13. For all courses associated with this fee or deposit, enter: - Subject - Four-digit course number - Course Title - Course Type Code (See Form for listing of codes.) Major Fee Data 14. Check all that apply to indicate the term for which the major fee should be charged. 15. Six-digit Academic Program Code (See SPI 66). 16. Description of Academic Program Code. Approvals 17. Signature of the appropriate Dean, Director, or Campus President. 18. Signature of the appropriate Senior Officers or Provost, as indicated. TO BE COMPLETED BY THE OFFICE OF BUDGET, PLANNING AND ANALYSIS: 19. Check one to indicate whether fee is appropriate or inappropriate in relation to the University system of budgetary control. 20. Verify account number for deposit of fee or deposit income. 21. Complete Impact Statement. TO BE COMPLETED BY THE PROVOST'S OFFICE: 22. Signature of the Provost.