Request For Reimbursement For Damages To Student Property

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MU 6/94
Request for Reimbursement
For Damages to Student Property
Date Prepared ___________________________ Incident Date/Time __________________________________
Incident Location ________________________________________Phone # ____________________________
Student Name ______________________________________ Social Security # _________________________
Description of incident: (How did the damage occur? Why is the University responsible?)
_________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Property Damage Description:
Item
Value
_________________________________
________
____________________________________
_________
____________________________________
_________
____________________________________
_________
____________________________________
_________
____________________________________
$ __________
Student Signature
Total
Confirmation (Residence Hall Director or Assistant Residence Hall Director)
This is to confirm that I have seen the damaged item(s) and that they appear to have been damaged as a result of
the incident described above. The estimated value(s) for these items(s) appear to be reasonable.
______________________________________
_________________
Name
Campus Phone #
______________________________________
__________________
Signature
Date
COMMENTS:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Copy 1 – Purchasing
Copy 2 – Residence Hall Director

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