Refund To:
Note: Refund will only be issued to Payee
NAME:
ADDRESS:
CITY, STATE, ZIP:
TELEPHONE #:
EMAIL :
Reason for Request:
Name of children refund pertains to (if applicable):
Method of Payment: (Type an X by all methods that apply)
Check, Money Order or Cash
Debit/Credit Refund
AP will route through Treasury
Last 4 #'s of Credit/Debit Card
(If unknown, processor will fill in)
Refund Requested by: (Payee Signature)
Date:
Date of Deposit: Receipt No.:
GL Account No:
(MDC/CCP-related refunds only should be GL #251425)
Cost Center:
Proof of cleared transaction attached?
YES NO
Total Amount Paid: $
Printed Department Contact Name & Phone
Department Manager Approval (Signature) / Date
Refund Request
Bernalillo County Parks, Recreation & Open Space
OFFICIAL USE ONLY
_____________________________________________
(Payee, please do not write in Official Use Only area.)
Please make sure to deduct registration fees from
your requested amount as these are non-refundable.
Department Director or
Elected Official
SIGNS HERE >>>>>>>
___________________________________________
Total Amount
of Refund after
deductions: $
Date
Please enter today's date:
Amount of Refund: $
Please select one Community Center
or Program from the following
drop-down menu options:>>
Name of the program registered for:
Please Select One:
click to sign
signature
click to edit
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