PAYEE NAME:

AMOUNT:

$

(PLEASE PRINT or TYPE)

STUDENT

STUDENT NAME:

NUMBER:

(PLEASE PRINT or TYPE)

ACCOUNT CODE

(BUDGET)

ADDRESS

PHONE:

CITY

STATE

ZIP

REASON FOR REFUND

ORIGINAL RECEIPT #

□

Cash or

□

Check

POS-REFUND RECEIPT #

AUTHORIZED BY:

ASB Treasurer

Date:

Student Representative

Date:

FOR ACCOUNTING USE ONLY

Verification in POS

Date

Initials

Deposit Verification

Date

Initials

Revised Oct. 2007

ASB REVENUE REFUND AUTHORIZATION FORM

Rev. 11/07

Section 9.2

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