Revised: 1-2018
BRCC BLUE CARD REFUND REQUEST
Please accept this form and attached documentation as my formal request to have my Blue Card balance(s) refunded.
I understand that if approved my refund check will be mailed to the current address on file in the BRCC Student
Information System (SIS) and/ or HRMS. Refund(s) may be approved provided sufficient documentation is provided for
the following reasons:
Major medical emergency—involving the extended incapacitation/hospitalization of the student documented by a
physician’s statement or other medical support. This must be an unscheduled medical emergency; pre-
existing conditions are not allowable as a reason for refunds.
Extreme financial hardship—involving the sudden, unforeseen loss of an extreme nature. An example of
such an extreme hardship would be the loss of the student’s home through fire or flood.
Death of a student’s immediate family member—with certification. Immediate family is defined as father,
mother, stepfather, stepmother, spouse, sibling, stepbrother, stepsister, stepchild, or your child.
Institutional errors by BRCC personnel that cause discrepancies in your account balance.
A national emergency or mobilization declared by the President of the United States and in accordance with
Section 23-9.6.2 of the Code of Virginia.
Emplid ID#___________________________________________________________________________
NAME: ______________________________ _________________________________ _____________
Last First Middle
ADDRESS:________________________________________________________________________________
_______________________________________________________________________________
SEMESTER:
Summer 20____
Fall 20____
Spring 20____
_______________________________________________________ __________________________
Student Signature Date
Return form to with attached documentation to:
Director of Finance and Facilities
Armstrong Hall—Room 105C or mail to:
PO Box 80, Weyers Cave, VA 24486
Director of Finance and Facilities action:
Refund Approved
Refund Approval Declined
___________________________________________________ ____________________
Director of Finance and Facilities Signature Date
For Business Office Use Only:
Check#________________ Check date:_______________ Amount:_________
