1. REFUND REQUEST FORM
      1. TO BE COMPLETED BY STUDENT:
      2. TYPE OR PRINT:
      3. ***STUDENT MUST COMPLETE THE SECOND PAGE OF THIS FORM***
      4. TYPE OR PRINT:
      5. **** STUDENT MUST SUBMIT ORIGINAL FORM TO BURSAR’S OFFICE****
      6. RECEIVED BY BURSAR: 
      7. RECOMMENDATION OF REFUND COMMITTEE: 

 
 
 
 
 



REFUND REQUEST FORM

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TO BE COMPLETED BY STUDENT:


Refund Requested by:
     Name of Student         Student I.D. #


Address:
   Street Address      City      State    Zip code
 
Contact Phone #


Supporting Documentation Attached?               Yes   No  
 
Read and carefully follow the instructions on this form to ensure your request may receive fair consideration. Lack of specific information and failure to supply accurate dates will adversely impact response to your request.


Semester/Year
 

Date of drop Course/Section Credit Hours
     
     
     

Date of drop Course/Section Credit Hours
     
     
     

 

 

Provide a carefully detailed chronological explanation of why you feel you are justified in requesting a refund. Attach additional documentation, such as letters from physicians, etc., to support your explanation. You must provide dates in your explanation.
 




TYPE OR PRINT:
 
 



***STUDENT MUST COMPLETE THE SECOND PAGE OF THIS FORM***
Form 1143/001 (3/13) Page 1 of 2

Explain in careful detail the payment arrangements you made for that semester. Your statement should particularly include: (1) an explanation as to how any financial aid arrangements related to your payment and (2) what is the current status of your student account for which you are seeking a refund.
 




TYPE OR PRINT:
 
 
______________________________  ____________________
Student’s Signature        Date
 



**** STUDENT MUST SUBMIT ORIGINAL FORM TO BURSAR’S OFFICE****

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RECEIVED BY BURSAR:  
         _________________________________  ___________________
         Signature of Bursar’s Office Staff    Date
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RECOMMENDATION OF REFUND COMMITTEE:  
 

Refund Approved    Refund Disapproved              % of Refund
 
COMMENTS:

   
 
   
 
 

 
 
 
    _____________________________________________    ___________
Signature, Refund Committee Chair        Date
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APPEAL to Vice Chancellor for Business & Administrative Affairs (If applicable):
 
 

 Refund Approved    Refund Disapproved   ____________________________________  ___________
 Signature, Vice Chancellor, Business &    Date
 Administrative Affairs

 
 

 
Form 1143/001 (3/13) Page 2 of 2

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