Refund Request Form - IUPUI Parking & Transportation

Refund Request Form

(Form must be completed for processing)

Customer Name: Billing/Campus Address: City, State: Student/Employee ID #: Original Payment Method (Circle One):

Reason for Refund Request:

To submit request: Download form, complete in full and send form by email to permits@iupui.edu or fax (317)274-5812.

Customer Contact Information

Phone #:

Date:

Zip:

Check Jagtag

Cash Payroll

Email Address: Permit/Citation #: Credit Card CC Last 4 Digits: Bursar CC Expiration Date: Customer Signature:

This form is a refund request. Approval is not guaranteed. If approved, refund will be issued in form of original payment except cash

(which will be paid via check). If disapproved, customer will receive an email notification with explanation. Thank you.

Date Received at

**********Do Not Write Below this Line. Office Use Only.********** Parking Services Clerk Review

PTS:

Original Sales Receipt #:

Amount Processed:

Date Processed:

Account Deposit #:

Notes in Flex: Yes / No

Flex Activity Attached: Yes / No Notes:

PTS Employee (processing refund):

Date Reviewed: Signature: Notes:

Date Processed: Object Code: PTS Employee (processing):

Refund Approval (Management)

Approved: Yes / No Approved Credit Amount:

Flex Voucher #:

Payroll Report Attached: Yes / No / NA

Refund Processing (Accounting/Billing Specialist)

Verified Payment Type:

Refund Database Updated: Yes / No

Refund / Receipt Confirmation #:

Notes:

Refunds associated with Permit and Service Order Form follows a separate procedure. Thank you! Revised: HAS 9/12/2018

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