Request for Refund

Instructions for Completion:

1. Name to whom the refund check is to be made payable.
2. Social security number, student ID number, or taxpayer ID number.
3. Address, including city, state, and zip code.
4. Reason for the refund.
5. Account number to which the receipt was originally deposited.
6. Source code which was originally used to make the deposit.
7. Amount
8. Number of the receipt which was written when the funds were received.
9. University unit head or other individual authorized to request the refund.

Last Updated June 28, 2007