Attach
Parking
Permit
Here
Refund for: Sac State ID #
Address
Email Address Non-Resident Student Yes No
Phone # Semester Amount Requested $
Reason for Request
Refund Type: Other
Parking (staple permit in box to the right) Appeal (attach supporting documents)
Sponsored or Fee Waiver Reimbursement OneCard Hornet Bucks
B
y signing below, I certify that I understand the Bursar’s Office Refund Policy found at csus.edu/apply/enrollment-costs-fees/
refunds/policies-procedures.html and that this refund may incur a $10.00 refund processing fee.
Signature Date:
Department Name Permit Decal #: Returned in T2 by
Approved Refund Amount $ Comments:
Account Chartstring Information:
Departmental Authorization by personnel authorized to sign for the above account:
Printed Name Phone Number Signature Date
University Debts? No Yes (Amount applied to debt $ Check # Date )
Waived $ Refunded $ Check # Date
Semester
Refund Technician Signature Date
APPEAL: Approved Denied Voucher # RM #
Comments:
Approving Signature Date
Dept ID Account Fund Class Amount Type of Fee
REQUESTOR INFORMATION
(Please print)
Street City State Zip Code
DEPARTMENTAL AUTHORIZATION
(For department office use only)
BURSAR’S OFFICE AUTHORIZATION
(For Bursar’s Office use only)
FOR FILING PURPOSES: Last Name _________________________________________ First Name _________________________________________
Initials & Date
First Name Last Name (or company name)
California State University, Sacramento
Bursar’s Office
6000 J Street, MS 6052
Sacramento,
CA 95819
Phone: (916) 278-1000 #3
Fax: (916) 278-6243
Refund Application
Please submit completed form to the Bursars Office in Lassen Hall, Room 1003.
(Submission of this form does not guarantee a refund. You will be notified of a
decision by check, eRefund or email. The $33 Payment Plan Fee, $25 Late
Registration Fee and $100 Reenrollment Fee are non-refundable.)
cs
us.edu/administration-business-affairs/internal/aba-forms.html
Updated: October 2019 (KJR)
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