Encumbrance Submittal Form - Purdue University Office of the Dean of Students

Did the student live in the house the entire time this debt was incurred?
Is the encumbered student a candidate for graduation?
Is the encumbrance for a debt that was incurred during the current semester?
I have personally notified the student that they are being encumbered.
I understand that I must submit an encumbrance removal form before the encumbrance will be released.
Please complete all information included in this form. This form is not complete unless a signed copy of the contract for the time in which the debt was incurred is submitted below.
Name of Group Requesting Encumbrance
Student's Full Name
Student's Complete Address
Student's PUID #
Encumbrance Amount (Minimum Amount of $200)
Room ($)
Board ($)
Dues ($)
Other ($) (explain)
Total ($)
These charges were incurred the month(s) of:
Required
Required
Treasurer Printed Name
Treasurer Phone Number
Treasurer Address (During Break, if Applicable)
President Printed Name
President Phone Number
President Address (During Break, If Applicable)
Please Upload Signed Contract for Time in Which Debt Was Incurred: