Office of the Bursar
Division of Finance and Administration
145 College Road Suffern New York 10901-3699
Phone (845) 574 4254 Fax (845) 574 4737
Refund/Overpayment/Credit Form
Student ID: __________________ Contact Number: _________________________
Last Name: __________________________________ First Name: ____________________________
Address: ____________________________________ City: _____________ State: ___ Zip: _________
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Semester 20_____ FA WI SP S1 S2 S3
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You must officially drop course(s) at the Records Office before submitting this form.
Student Signature: ______________________________________ Today’s Date: _________________
DO NOT WRITE BELOW THIS LINE
Bursar Office Action Taken:
Overpayment Form Submitted by _______________
Credit of $ _________ To pay term: ______ (Payable to RCC)
Notes:
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Term: __________ Voucher # ______________________ Amount $ __________
Term: __________ Voucher # ______________________ Amount $ __________
Total Refund $ ___________
Please Attach current XARC date 04/01/99
No
