Student Housing Third-Party Rent Payment Authorization Form
Student Information
Student Name
Student ID Number
Phone Number
Email Address
Housing Address
Third-Party Payer Information
Name of Third-Party
Relationship to Student
Organization (if applicable)
Phone Number
Email Address
Billing Address
Authorization Details
Amount to be Paid
Frequency
One-time
Monthly
Quarterly
Per Semester
Start Date
End Date
Additional Notes
Authorization Agreement
By signing below, both the student and the third-party payer authorize payment according to the terms above.
Student Signature
Date
Third-Party Signature
Date