Third Party Billing Authorization

Please complete the information below for third party authorizations.

Important Information

This Third Party Billing Authorization must be completed each term before we can bill for your charges.

Third Party Billing Authorizations must be turned in within a timely manner in order for us to bill for your charges.

Completing this form does not guarantee authorization from your third party sponsor. Students must turn in an authorization from their third party sponsor in addition to this authorization.

The Treasurer's Office will review information entered and you will be contacted if additional information is needed. By entering your information, you understand and agree to the following terms and conditions:

Terms and Conditions
1. I am responsible for making payment by the fifth (5th) class day for charges that are not authorized by my third party sponsor.

2. I will be responsible for providing timely information as requested by either the Treasurer's Office or my third party sponsor regarding this authorization.

3. If the Treasurer's Office does not receive payment from my third party sponsor by the end of the subsequent term to which this agreement applies, I will be responsible for the balance not paid and my account will be placed on hold and I will not be permitted to register or receive a diploma or transcript.

4. I understand the Treasurer's Office reserves the right to refuse to bill my third party sponsor if there is a pattern of non-payment from my third party sponsor in past terms.

5. I understand that this authorization does not relieve me from any financial responsibilities to Arkansas State University since I am ultimately responsible for my entire student account balance. I understand if I have an unpaid balance to the University and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I understand and agree that I will remain responsible for payment of my student account balance and I shall be responsible for any reasonable attorney fees and the costs associated with the collections of my unpaid charges, which may include fees charged by a collection agency up to 50% of the unpaid charges collected by that agency. I also understand my failure to pay may result in credit bureau reporting or state income tax attachment, as permitted by Arkansas law.

6. I understand that I must file a Third Party Billing Authorization with the Treasurer's Office at the time of registration for each term.

7. I authorize Arkansas State University to provide my third party sponsor course and financial information pertaining to my enrollment under this authorization.

8. In order for the Treasurer's Office to bill my third party sponsor, I must submit a copy of my sponsorship/award to the Treasurer's Office, in addition to this authorization.

9. I consent to being contacted on all phone numbers, including cell phones, provided to the University as a source of contact. This includes contact from its agents, representatives, and attorneys (including collection agencies) for purposes of collecting any portion of my financial obligation which is past due.

Note: The price will show zero upon completion of your order as it is only used to collect necessary information.