Refund Request Form printable pdf download

Office of the Bursar

PO Box 392

REFUND REQUEST

Old Westbury, NY 11568-0392

Tel: 516-686-7510

NOTE: Refunds are issued according to your selected

Fax: 516-686-7833

BankMobile

refund disbursement option.

*** ALL INFORMATION MUST BE COMPLETED AND THE FORM SIGNED ***

___________________

DATE:

STUDENT NAME

____________________________________________________________

ID #

_____________________________

REFUND AMOUNT_______________________________ SEMESTER(S) __________________________________

Please Refund Recent Credit Card Payment back to Credit Card (Note: MUST BE A RECENT CREDIT CARD

PAYMENT, otherwise the refund will be issued according to your selected BankMobile refund disbursement option.)

CURRENT ADDRESS:

House Number/Street__________________________________________________________________________

Apartment No. __________________________

City, State, Zip _____________________________________________________________________________

Home Telephone # _______________________________ Cell #______________________________________

Email Address ______________________________________________________________________________

Current student paper check refunds are mailed to the address confirmed in your BankMobile student profile. If

this is a new address, you must update this information on the BankMobile student website. Go to

, log in, and click on the "user profile" dropdown.

I have read this form and understand the refund conditions:

Student Signature:______________________________________________________________________________

Date

Received by: ________________________________________________________________________________

Signature Bursar Representative

Date

Incomplete request forms will NOT be processed. The refund Department will make the final determination of

refund eligibility according to Federal Title IV Regulations. ADDITIONAL PROCESSING TIME MAY BE

NECESSARY DURING TIMES OF PEAK REFUND VOLUME.

Ref Request: mfd 7/1/16

Refund Request Form