Division of Business and Financial Affairs
Student Business Services
One University Drive
Camarillo, CA 93012
Phone (805) 437-8810
One University Drive, Camarillo, California 93012-8599 Tel: (805) 437-8810 Fax: (805) 437-8900 www.csuci.edu
REQUEST FOR SPECIAL CIRCUMSTANCES REFUND
FORM
Name:_____________________________ ID#: ________________________ Date:____________
Address:____________________________ City, State, Zip:_________________________________
Primary Phone:_______________________ Email:________________________________________
Instructions: Title V of the State Education Code has specific allowances for approval of refunds after the published
deadline. In The space below, please provide a detailed explanation why you are requesting a refund or a reversal of
outstanding charges past the deadline.
Please write legibly and attach supporting documentation as needed.
Please allow 4-6 weeks for outcome: correspondence will be sent via email
Students Signature:__________________________________________ Date:_____________________
FOR DEPARTMENT USE
Request Received by:_____________________________________________ Date:_____________________
Approved_______ Denied________
Associate Vice President Signature:___________________________________ Date:_____________________
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