Contents
Cal Poly Pomona

Petition to Establish or Adjust a Campus Based Fee

Instructions:

Refer to Executive Order 1054 - California State University Student Fee Policy and Miscellaneous Course Fee Delegation of Authority.

Completed petitions should be forwarded through the line organization to the appropriate vice president with a letter of endorsement.  The petition is then forwarded to the Office of the Vice President for Administrative Affairs for inclusion on the agenda for the next meeting of the University Fee Advisory Committee.

Note:  Fee Committee guidelines include a one-quarter wait period before new fees can be charged or existing fees adjusted.

Questions regarding the completion of this form can be referred to Kathy Harper, Assistant to the AVP, Finance & Administrative Services for Administrative Affairs and Staff to the Fee Advisory Committee.  Kathy can be reached on extension 4509 or email kmharper@csupomona.edu.  Budget questions should be directed to Mark Lopez, Director of Budget Services.  Mark can be reached on extension 2928 or email fmlopez@csupomona.edu.


A. Is this proposal for a new fee or an adjustment to an existing fee?

B. Please circle the fee category (see Executive Order 1054 for definitions):

Category II          Category III          Category IV          Category V

C. Name of Fee:  ___________________________________________________________ (A Miscellaneous Course Fee should include both course name and number)

Complete Section D if you are requesting an adjustment to an existing fee.  For a new fee, continue to Section E.

D. Current fee rate:     Fall $ ____     Winter $ ____     Spring $ ____     Summer $ ____

Please provide the following information for the past fiscal year (note:  year-end revenue, expenses and balance should match the information contained in the University or Auxiliary Financial System:

Fiscal Year

Year-end Revenue

Year-end Expenditures

Year-end Balance

 

_______________

 

$ _______________

 

$ _______________

 

$ _______________

E. Proposed fee rate:  Fall $ ____     Winter $ ____     Spring $ ____     Summer $ ____

Provide the following “year 1” projections for both new and adjustments to an existing fee.  Complete and attach the Fee Revenue and Expense Worksheet.

Fiscal Year

Year-end Revenue

Year-end Expenditures

Year-end Balance

 

_______________

 

$ _______________

 

$ _______________

 

$ _______________

F. Revenue projections – year two.   Complete and attach the Fee Revenue and Expense Worksheet.

Fiscal Year

Year-end Revenue

Year-end Expenditures

Year-end Balance

 

_______________

 

$ _______________

 

$ _______________

 

$ _______________

    G. Please briefly summarize the purpose of the fee including a justification of the need for the fee.  If this is a current fee, please include a history of the fee (When was the fee first established ?  When was the fee rate last adjusted?).

    Click here to download this form in Word

    Revised November 2012